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W <br /> GUIDELINES A THE MEDICAL WASTE MPAGEMENT 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: '� �° JA 2i C <br /> Business Address: CJ_ okc Ira S-a?d <br /> Business Phone: (o?0) '!6 - 3 -Z71 -' x T 6e 7 <br /> Type Of Facility/Business: 11161il s- di- e 7,Y <br /> Registered As: (Check One) <br /> (t< Small Quantity Generator With Onsite Treatment. (Generates<200 lbsJmo.) <br /> ( ) Large Quantity Generator. (Generates 200 lbs.or more/mo.) <br /> () Large Quantity Generator With Onsite Treatment. (Generates 200 lbs. or more/mo.) <br /> () Common Storage Facility(Small Quantity Generators only.) <br /> Person Rqponsible FA Implementation Of The Plan: <br /> Name: 6 4 W r Title: /R-- 4/•')1 done: (gel)-316 -t 7' <br /> ATTACH THE FOLLOWING ADDITIONAL INFORMATION 7 sr 7 <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 /> 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 /> h. Describe your medical waste emergency action plan, including procedures for handling spills, <br /> exposures,equipment failures, etc. <br /> I hereby certify that tcp the best of my knowledge and belief that the statements made herein are correct and true. <br /> SIGNATURE: XX TITLE: r&, dF CA®M` ATE: 1* 99, <br /> � �I/d e-SS <br /> 5 <br />