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I <br /> { <br /> Phone: ( ) <br /> g. Name, address and phone number of Offsite Treatment Facility where pharmaceutical <br /> waste is transported for treatment,if different than pharmaceutical waste hauler: <br /> Name: Y �/C. <br /> Address: <br /> & r <br /> City State Zip Code <br /> Phone: 13 61 <br /> h. All medical waste generators are required to keep accurate records regarding <br /> containment,storage,hauling,treatment and disposal. All medical waste records area to <br /> be maintained and available for review during inspection for three(3)ye rs. Do you <br /> have tracking documents for all medical wastes handled at your facility: XYes❑No <br /> i. Describe training provided to staff regarding handling,storage,disposal,and record <br /> keeping of all medical waste,including pharmaceutical waste,at your facility: <br /> J. Describe your medical waste emergency action plan, including procedures for <br /> handling spills,exposures, equipment failures, etc: <br /> I hereby certify to the best of my Knowledge and belief that the statements made herein are <br /> correct and true. <br /> Signature: <br /> Printed Name: <br /> Title: tont C� <br /> Date: <br /> — /op <br /> E11D 4s-03 <br /> 10,'6,,2006 7 <br />