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11/22/2010 14:12 2099 -) 536 RENAL ADVANTACIE A28 PAGE 02/02 <br />Phone: <br />!;. Name, address and phone number of O.ftsite `l,resatment Facilx <br />waa#e is transported .for treatment, if different thty Where pharrgaceutical <br />Name: an pharmaceutical Waste hauler: <br />%(• t ' <br />Address: <br />City ��— <br />State <br />Phone: Zip Code <br />h. All medical waste generators are required to keep accurate records regarding <br />eontai.n►r M)t storage, i'Muling, treatment and disposal. All medical waste aecoads area, to <br />be maintained and available for review during inspection fol three (3) years ho you <br />have tracking doeu.mEnt.� for all medical wastes handled a$your facility: Q Yes 0 No <br />Describe fll d <br />training provided <br />kcel�in to staff regarding handling, storage, disposal, and record <br />oanaCiea] Waaste, including harma eutic:ll waste, at your facilit <br />J Describe your medical waste emel-getley action plan includin ,Paocedures :for <br />_ handling spil.ts, exposures, equipment failures, etc: <br />A4 1 <br />_ .--� <br />)C licrehy certify to the best i;Fwn know @l dge an®l�fthAt ti <br />COI A'@Ct <br />and true. i4 8ti1tCi11@►ItS Mede herein are <br />Signature: <br />Printed N <br />Title. <br />Dafic: �� <br />F.-IiD 45-03 1 <br />t0ierzr�nr <br />