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06/20/2011 03:52 209339401-dV ADMINISTRATOR PAGE 06/06 <br /> MEDICAL WASTE DATA FORM (Attachment 1) <br /> 1- TYPES OF BIOHAZARDOUS WASTE GENERATED AT FACILITY <br /> Laboratory Waste <br /> Blood or Other Potentially Infectious Material <br /> 2. ESTIMATED MONTHLY AMOUNT OF BIOHAZARDOUS WASTE GENERATED AT <br /> THE FACILITY. - lbs per month <br /> 3. SPECIFIC FACILITY MEDICAL WASTE-HANDLING PROCEDURES <br /> • Attach map of facility noting Biohazardous waste storage closets and enclosure <br /> areas. <br /> STORAGE AREA DESCRIPTION <br /> 1. Duration of storage <br /> 2. Temperature controls YES NO <br /> . If yes, then what are required temperatures? <br /> ONSITE TREATMENT <br /> YES NO <br /> If yes, then describe <br /> REGISTERED HAZARDOUS WASTE HAULER <br /> Name <br /> Address <br /> Phone Number <br /> Registration Number <br /> OFF SITE TREATMENT FACILITY <br /> Name <br /> Address <br /> Phone Number <br /> LIMITED QUANTITY HAULING EXEMPTION <br /> Yes No If yes, then who on staff is authorized to transport medical <br /> waste? <br /> MEDICAL WASTE EMERGENCY ACTION P1. LAN <br /> HANDLING BLOOD SPILLS (Contaminated work surfaces shall be <br /> decontaminated with a chemical germicide approved for use as a "hospital <br /> disinfectant" and is tuberculocidal when used at recommended dilutions <br /> immediately or as soon as feasible after any spill of blood or other <br /> potentially infectious materials.) <br /> 2. EXPOSURES <br /> 3. EQUIPMENT FAILURE <br /> Biohnodous Waste Plan <br />