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GUIDELINES FOR WE MEDICAL WASTE MANAEMENT PLAN <br /> (Please Type or Print) <br /> Small quantity generators that provide onsite treatment and all large quantity generators shall have a medical waste <br /> management plan on file with the local enforcement agency. Minimum required information: <br /> Business Name: Ni2kc, <br /> Business Address: U <br /> Business Phone: :1 -'Rio b2- <br /> Type Of FacilityBusiness: 21-aar,r,�t►"�,, 'e �& <br /> Registered As: (Check One) <br /> ( ) Small Quantity Generator With Onsite Treatment. (Generates <200 IbsJmo.) <br /> Large Quantity Generator. (Generates 200 lbs. or more/mo.) <br /> ( ) Large Quantity Generator With Onsite Treatment. (Generates 200 lbs. or more/mo.`, <br /> O Common Storage Facility (Small Quantity Generators only.) <br /> Person Responsible For Implementati Of The Plan: <br /> Name: 3Pbat l Title: ( ,,,-AP22 11j f-P CAy <br /> ` DAina� Pie PN3 ATTACH THE FOLLOWING ADDITIONAL INFORIYIATION <br /> 1. List the types of regulated medical waste generated at your facility(refer to list on page 2). <br /> 2. Estimate the monthly amount, in pounds, of medical waste generated at your facility. <br /> '7 :SO Ptv.,-XA s <br /> 3. Describe the medical waste handling procedures utilized by and applicable to your facility: <br /> a. Onsite location and method for segregation, containment, packaging,.labeiling, and.collection. <br /> b. Storage area description with storage methods utilized, including duration and temperature <br /> controls, if applicable. <br /> See 1\-'l LWA <br /> C. Onsite treatment facility description, including type of treatment utilized, maximum capacity, time <br /> and temperature necessary, alternate contingency plan in case of equipment failure, etc. <br /> >ee- kwcce""A <br /> d. Name, address, registration number, and phone number, of the .iazardous waste hauler <br /> employed by your facility. ar-� �"1� `�``l 5ysw,s <br /> (9-��c) Co3itC�bOn <br /> t�� <br /> �cancho Crr�4`ucl, GPt- <br /> e. Name, address, and phone number of offs4e_treatment facility where medie?� waste is transported <br /> for treatment, if different than the hauler. ri� µc'd`'C°`� SYs � L'? <br /> 4r3.5 W -�-09gL <br /> f. Do you have a Limited Quantity Hauling Exemption? Who on your staff is authorized to transport <br /> your medical waste? A <br /> g. Do you have tracking documents for all medical wastes handled at your facility? All medical <br /> waste generators are required to keep accurate records regarding containment, storage, hauling, <br /> treatment and disposal. All medical waste records are to be maintained and available for 3 years. <br /> "J e> <br /> h. Describe your medical waste emergency action plan, including procedures for handling spills, <br /> exposures, equipment failures, etc. <br /> si!0, lkOwd <br /> I hereby certi at to the bet of my knowledge and belief that the statements made herein are correct and true. <br /> 19j— <br /> SIGNATU TITLE: GVH- .fr- DATE: /-/1M <br /> 5 <br />