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GUIDELINES FOR THE MEDICAL WASTE MARAGEMENT 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: LxU Meworial Hospital West <br />Business Address: 800 S. Lower Sacramento Rd., Lodi., CA 95_240 <br />Business Phone: (209) 334-3411 <br />Type Of Facility/Business: Acute Care Hose tal <br />Registered As: (Check One) <br />() Small Quantity Generator With Onsite Treatment. (Generates < 200 lbs./mo.) <br />Qt) Large Quantity Generator. (Generates 200 lbs. or morelmo.) <br />( .) Large Quantity Generator With Onsite Treatment. (Generates 200 lbs. or more/mo.) <br />() Common Storage Facility (Small Quantity Generators only_) <br />Person Responsible For Implementation Of The Plan: <br />Name: Donna !KC auley _ Titie:FaCilities C oordinat w Phone. (209) 339-7668 <br />kTTACH THE FOLLOWING ADDITIONAL INFORMATION <br />List the types of regulated medical waste generated at your facility (refer to list on page 2). <br />Estimate the monthly amount, in pounds, of medical waste generated at your facility. <br />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 />Describe your medical waste emergency action pian, including procedures for handling spills, <br />exposures, equipment failures, etc. <br />I hereby certify that to the best of my knowledge and belief that the statements made herein are correct and true. <br />SIGNATURE; AAA �%`� �!/��. TITLEf <br />5 <br />