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b. Storage area descrip on v <br />controls_ if anfllicable: / <br />c. onsite treatment facility description, including type of treatment utilized, maximum capacity, <br />time 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 />Name: <br />Address: <br />44 -Id <br />'City ����e� <br />Phone: ( S 4 Zip Code <br />Registration[lam- <br />e. Name, address and phone number of Offsite TwAtment Facility where medical waste is <br />transported for trentrment, if different than hauler: <br />Address: <br />City State Zip Code <br />Phone: <br />f. Do you have a Limited Quantity Mauling Exemption: Q Xes No <br />g. Who on your staff is authorized to transport your medical waste? (If more than 3 names, <br />attach a list). <br />List Names: 1. ! V o --� <br />2. <br />3. <br />h. All medical waste generators are required to keep accurate records regarding containment, <br />storage, hauling, treatment and disposal. All medical waste records area to be maintained and <br />available for review during inspection for three) years. Do you have tracking documents for <br />all medical wastes handled at your facility: Xes ® No <br />i. Describe your medical waste emergency action plan, <br />,ejposum.A, equipment failures, etc: <br />I hereby certify to t of <br />Signature: L.- <br />axn 45-02-W3 <br />MOM <br />for handling spills, <br />:9;-, -tea <br />belief that the statements made herein are <br />Page 6 of 7 <br />