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GUIDELINES ft THE MEDICAL WASTE GEMENT 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: <br />Business Addres <br />Business Phone: (JW) W+±: pd -:h <br />Type Of Facility/Business: 1 <br />Registered As: (Check One) <br />() Small Quantity Generator With Onsite Treatment. (Generates < 200 lbsJmo.) <br />O 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 Impleme tation Of The Plan: <br />Name: , V i t ( Title: / Phone: 2 <br />ATTACH THE FOLLOWING ADDITIONAL INFORMATION <br />1. List the types of reg fated medical waste generated at your facility (refer to list on page 2). <br />2. Estimate the monthly amo nt, 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 />Inc oLo 'c"aS i-2 <br />a. Onsite location and meod for segregation, containment, packaging, labelling, and collection. <br />b. Storage area descript'on with storage methods utilized, including duration nd tempe ture <br />contr Is, if ap lica le. 31 S. <br />Q <br />c. i Onsite treatment facility description, including type of treatment utilized, maximu capacity, time <br />J and temperature necessary, alternate contingency plan in case of equipment failure, etc. <br />d. Name, address, registration number, and phone nu ber, of the registered hazardous waste hauler <br />employed by your facility. <br />e. Name, address, and phone number of offsite treatment facility wherp medical waste is transported <br />for treatment, if different than the hauler. ( C <br />1-4) <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 Ian, iclu 'ng procedures for handling spills, <br />exposures, equipment failures, etc. /` <br />I hereby certify that tot a best of my knowledge and belief that the state en made herein are correct and true. <br />SIGNATURE: TITLE' DATE: <br />it <br />5 <br />