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a$ <br />Registration #: / (OT) T5/0:57 - <br />f, <br />7" 057- <br />f. Name, address and phone number of Offsite Treatment Facility where biohazardous <br />(excluding pharmaceutical waste) and sharps waste is transported for treatment, if different than <br />hauler: <br />Name: <br />Address: <br />City State Zip Code <br />Phone: <br />g. Name, address and phone number of Offsite Treatment Facility where pharmaceutical waste <br />is transported for treatment, if different than pharmaceutical waste hauler: <br />Name: <br />Address: <br />City State Zip Code <br />Phone: ( ) <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 (3) years. Do you have tracking documents for <br />all medical wastes handled at your facility: W Yes ❑ No <br />i. Describe training provided to staff regarding handling, storage, disposal, and record keeping of <br />all medical waste, including pharmaceutical waste, at your facility: <br />& -e 4 <br />e ®Aha t a <br />j. Describe your medical waste emergency action plan, including procedures for handling spills, <br />exposures, equipment failures, etc: i Sh _ A ersC-hVaAO <br />iatoyw,a4l hv li) ` > PPP- <br />I hereby certify to the best of my knowledge and belief that the statements made herein are correct and true. <br />Signature: Si�Title: 044-16— <br />Date: <br />/ Date: - e-0 <br />EHD 45-03 Page 3 <br />6/8/05 <br />