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rDrWASTE <br />(Please 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 aeencv. Minimum recuired information: <br />Business Name. <br />Business Address <br />Business Phone: <br />Type Of Facility, <br />Registered <br />() Small Quantity Generator With Onsite Treatment. (Generates < 200 IbsJmo.) <br />( Large Quantity Generator. (Generates 200 lbs. or more/mo.) <br />() Large Quantity Generator With Onsite Treatment. (Generates 200 lbs. or more/mo.) <br />() Common Storage Facility (Small Quantity Generators only.) <br />Person Respons'ble For plementation f The Plan: `- <br />�a <br />Name: ' f eK Title: _ Phone: —6 <br />ATTACH THE FOLLOWING ADDITIONAL INF6RMXTION �® <br />1. List the types of regulated medical waste gene ted at, your facility (refer to It t on pa a 2). <br />2. Estimate the monthly amount, in pounds, of medical waste generat y r facility. <br />3. Describe the medical waste handling procedures utilized by and applicable to your facility: <br />a. Onsite location and method for se regation, containment, packagin , lab-ing, an collection. <br />_50�-r � b a s 4 Nel-s r� <br />b. Storage area-. description with storage methods utilized, i lulling d ration and mperature <br />controls, if ap lic le. <br />/,� e w <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 Apundpus we hauler <br />q L7 employed by your facility. I � '" <br />((� �i <br />e. Name, address, and phone nuieer of offsite tream�ent-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 />h. Describe your medical waste emergency action plan, includi g procedures for h ing spills, <br />sir✓ exposures, equipment failures, etc.-T,13p <br />I hereby certi that to the best of my knowledge and belief that the statements made herein are co ect and true. <br />Q _ <br />SIGNATURE: TITLE. � DATE: <br />