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1868 E. Hazelton Avenue <br />Stockton, California 95205 <br />Telephone: (209) 468-3420 <br />Fax: (209) 468-8392 <br />FIMPINAILMrart �' <br />Small quantity generators that provide onsite treatment and all large quantity generators shall have a <br />Medical Waste Management plan on file with the San Joaquin County Environmental Health Department. <br />The Medical Waste Management Plan shall contain the following information as appropriate for your <br />facility: N <br />Business Name: <br />Business Address: <br />City State Zip Code <br />Phone Number: ('ICA ) A--Vl- m I <br />Type of Facility or Business: <br />REGISTRATION FOR: <br />Small Quantity Generator with Onsite Treatment (Generates less than 200 lbs/month). <br />Large Quantity Generator Only (Generates 200 Ibs or more/month). <br />❑ Large Quantity Generator with Onsite Treatment (Generates 200 lbs or more/month). <br />Person responsible for implementation of the Medical Waste Management Plan: <br />Name:M- - M r aj Com. Title: 1✓45�4`�1�� �j,,' [�( <br />Phone: l ) A' - t6ll t Date: -All <br />1. List the types of medical waste generated at your facility (i.e. laboratory wastes, blood or body <br />1 fluids, sharps, ctntaminated animals, surgical specimens, trace chemo or isolation wastes): <br />a) Do you generate any pharmaceutical waste (expired, spent, partials, patient returns)? >4 Yes ❑ No <br />describe the type of pharmaceutical waste <br />,(,,expired <br />A (expired, spent, partials, patient returns): <br />.. _ .. <br />And estimate the monthly amount of pharmaceutical waste generated at your facility: 1' wk'5 <br />EHD 45-03 <br />20I5 <br />