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GUIDELINES FOR MEI WASTE AMENT PLAIN <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: in ef cC,+Al JC oN.S -r_ <br /> Business Address: l= s T V 4¢av ® 2' <br /> Business Phone: 0 - Si <br /> Type Of Facility/Business Ahj 'uf IMC ('i) DAN <br /> Registered As: (Check One) <br /> ( ) Small Quantity Generator With Onsite Treatment. (Generates<2001bsJmo.) <br /> Large Quantity Generator.(Generates 200 lbs.or ore/mo.) <br /> ( ) Large Quantity Generator With Onsite Treatment. (Generates 200 lbs.or more/mo.) <br /> () Common Storage Facility(Small Quantity Generators only.) <br /> Person Responsible or Implementation Of The Plan: =an.S SG CtVE�o/`'Phone: f <br /> Name: R('C Ll�'4' Title: ef# <br /> ATTACH THE FOLLOWING ITIONAL INFORMATION <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 /> 3. Describe the medical waste handling procedures utilized by and applicable to your facility: <br /> a. Onsite location and method for segregation,containment, packaging, labelling, and collection. <br /> b. Storage area description with storage methods utilized, including duration and temperature <br /> controls, if applicable. <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 /> d. Name, address, registration number, and phone number, of the registered hazardous waste hauler <br /> employed by your facility. <br /> e. Name, address, and phone number of offsite treatment facility where medical waste is transported <br /> for treatment, if different than the hauler. <br /> f. Do you have a Limited Quantity Hauling Exemption? Who on your staff is authorized to transport <br /> your medical waste? <br /> 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 /> h. Describe your medical waste emergency action plan, including procedures for handling spills, <br /> exposures, equipment failures, etc. <br /> I hereby certify tha to the est of nowledge and belief that the statements made herein are correct an true <br /> SIGNATURE- <br /> TITLE: Say- /K DATE: <br /> S <br /> l <br />