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10/22/2010 10:01 FAX DAVITA BEN HOLT IA002/013 <br /> SAN JOAQUIN COUNTY 40 Date i IS110 <br /> ENVIRONMENTAL HEALTH DEPARTMENT PR <br /> r 0 <br /> 600 East Main Street, Stockton, CA 95202 <br /> (209)468-3420 <br /> MEDICAL WASTE INSPECTION FORM <br /> FacilityNam FacifityAddress SSSV3_ <br /> FacilityConta <br /> Ct <br /> Phone 4tM___&do <br /> INSPECTION TYPE; SRO U ti n e- DCO plaint DRe--inspection <br /> VIOLATION(S) <br /> Registration THE ITEMS BELOW REPRESENT VIOLATIONS OF THE CALIFORNIA <br /> 1.HSC Section 117955-Large Quantity HEALTH & SAFETY CODE (HSC): <br /> -6;-narator shall register with the enforcement <br /> agency prior to commencement of the <br /> medical waste. generation - <br /> _2•HSC Section 117903-Permit from the WTS 141 4�' -Ai Me CJJQ4k Avm, a it. Aw o <br /> enforcement agency required to treat n <br /> nv\mlrr'�JA'P* I -3- _ <br /> waste. <br /> —3.HSC Section 117890-No large LOG shall LA". 11:r M crw% XT00 tl�ig <br /> generate medical waste unless registered with the Rov;&L <br /> enforcement agency, <br /> —4.HSC Section 11 7895-SQG that treats med <br /> waste shall register with enforcement agency, <br /> —5.HSC Section 117900-Shall not haul med <br /> [ <br /> waste unless registered or obtained LGHE. !:K& <br /> &A, Qj <br /> 6."SC Section 117903-Shall not treat med 17JU64 01A% "WzVc!_ tD.1\44jp. <br /> waste without Permit from enforcement agency, — --- _I <br /> iA vi <br /> 7.14SC Section 117908-Common Storage --LhA <br /> Facility shall be registered with local enforcement <br /> agency. pr <br /> -A ......... <br /> Procedures `L_LALA_LQ2iA K"Ai AVO <br /> —13.HSC Section 117935.$QG MWMP <br /> _9.HSC Section 117943-SOO. Shall keep <br /> records for 3 years. 51UW'k I t) (6.; ArLie <br /> —10.HSC Section 11 7946-SOC not required to -1 <br /> register shall keep records for 2 veers, jtA- <br /> __11-HSC Section 117960-LdG shall file RAWMP 11 <br /> with enforcement agency, •— <br /> —1 2.HSC Section 11 7976-LQG shall keep <br /> records for 3 years. <br /> Transportation <br /> —%Onn"kh '61 ICA 1"1 <br /> —13.HSC Section 118030-LO.HE application, <br /> Treatment(Sto rage <br /> ___14.HSC Section 118135-Shall obtain a permit <br /> from the enforcement agency to treat medical &-l-6w,v (YVA 11 f.41 <br /> waste prior to tree i the waste. S <br /> __I S.HSC Section 118759-All treatment records <br /> shall be kept for 3 years. 111A4 h Q.<& <br /> —1 6.HSC Section 118215-All medical waste <br /> shall be treated pursuant to this section. <br /> —1 THSC Section 118220-Recognlzable human Wash Ccs <br /> anatomical parts shall be disposed of by interment <br /> unless otherwise hazardous, AN <br /> IG.HSC Section 118225-Treated sharps shall <br /> 16—adastroyed or somehow prevent pubilca=ess. e fU43-a" in^. -T -MWMR <br /> _&-i 9.HSC Section 113275-MVV red begs,path, <br /> chemo shall be labeled properly, SCA-Lk� W Lau s <br /> 20.HSC Section 118280-MW label&contain <br /> _21.HSC Section 118286-Sharps label/contain 6'r <br /> 22.H$C Section 118295-Properclecon used. Ca `r Vj I <br /> _eHSC Section 118307-interim storage labeled <br /> 24'HSC Section 118310-Enclosure labeled. u V, <br /> —25.HSC Section 118305-Cannot rause drums <br /> _26.HSC Section 717530-Approved biohazard <br /> A9 <br /> bag used- <br /> 27.HSC Section 118275(8)-Pharm label/store <br /> 28.HSC Section 118222-Incineration Required Insp(Qior Signature Received Tate <br /> __�29 Other-Describe in narrative. F3v/ <br />