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i i <br /> Phone: L ) <br /> g. Name, address and phone num ler of Offsite Treatment Facility where pharmaceutical <br /> waste is transported for treatm,nt, if different than pharmaceutical waste hauler: <br /> Name: _ <br /> Address: _ <br /> City State Zip Code <br /> Phone: L ) <br /> h. All medical waste generators z re required to keep accurate records regarding <br /> containment, storage, hauling,treatment and disposal. All medical waste records area to <br /> be maintained and available fcr review during inspection for three(3)years,,Do you <br /> have tracking documents for a.1 medical wastes handled at your facility: e_l Yeso ®` r\.L <br /> LAO <br /> i. Describe training provided to staff regarding handling, storage, disposal,and record <br /> keeping of all medical waste, including pharmaceutical waste,at your facility: <br /> q C l° Yo n <br /> IPz s i�jc— <br /> j. Describe your medical waste emergency action plan, including procedures for <br /> handling spills, exposures, oquip ent failures, etc: (2'&J4 <br /> 2 <br /> r�, <br /> I hereby certify to the best of my knowledge and belief that the statements made herein are <br /> correct and true. <br /> Signature: <br /> Printed Name: fJ e <br /> Title: 0CAD r- 0+ <br /> Date: ® to/ 20 t 2-- <br /> EHD 45-03 7 <br />