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09/06/2012 14:49 209473'''' 9 BUSNINESSOFFIO PAGE 06/06 <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: c <br /> Address: <br /> City State Zip Code <br /> Phone: <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)years Do you <br /> have tracking documents for all medical wastes handled at your facility: Yes ❑No <br /> i. Describe training provided to staff regarding handling, storage, disposal, and record <br /> ke ing9kf all medical waste,iucludin barrnaceut cal waste,at your ility: <br /> ef <br /> j. Describe your medical waste emergency action plan, including procedures for <br /> handling spill a osur s,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 /> 4 Signature: Ell <br /> -? <br /> Printed Name: <br /> Title: A 'Aya�'[�7'�,�f;•'�_ <br /> Date- <br /> EM 45,03 7 <br /> rnrc"'0' <br /> Received Time Sep. 6. 2012 2: 45PM No- 0247 <br />