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b. Storage area description with storage methods utilized, including duration and temperature <br /> controls, if applicable: <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 /> City State Zip Code <br /> Phone: ( ) <br /> Registration M <br /> e. Name, address and phone number of Offsite Treatment Facility where medical waste is <br /> transported for treatment, if different than hauler: <br /> Name: <br /> Address: <br /> City State Zip Code <br /> Phone: 1 <br /> f. Do you have a Limited Quantity Hauling Exemption: ❑ Yes❑ 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. <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(3)years. Do you have tracking documents for <br /> all medical wastes handled at your facility: ❑ Yes❑ No <br /> i. Describe your medical waste emergency action plan, including procedures for handling spills, <br /> exposures, equipment failures, etc: <br /> I hereby certify to the best of my knowledge and belief that the statements made herein are correct and true. <br /> Signature: Title: Date: <br /> EHD 45-02-003 Page 6 of 7 <br /> 10/6/2003 <br />