INFORMATION PACKET
MEDICAL WASTE GENERATORS
This packet contains the information and forms you will need to help you comply
with the Medical Waste Management Act.
Instructions
1.
Complete the Medical Waste Generator Application Questionnaire form
(page 1). If your answers indicate you are a Small Quantity Generator not
required to register then complete the certification form (page 2), the
information document form (page 3) and return the completed forms with
the $144.90 administrative review fee. The administrative review fee will
cover a two year period.
2.
If you meet the requirements of a Large Quantity Generator or a Small
Quantity Generator required to register as indicated by affirmative
answers to questions 2 and 3 on the Medical Waste Generator Application
Questionnaire, then:
a.
Complete the Registration Form,
b.
Return the completed forms and,
c.
Contact Yuba County Environmental Health for the current fee
schedule and the Medical Waste Management Plan Packet.
Your cooperation in promptly registering and most importantly, in following the
specified handling requirements, is greatly appreciated. Your interest in
protecting public health and safety is the key to ensuring proper handling of
medical waste.
If you have any questions regarding registration or handling requirements, please
contact Env. Health at (530) 749-5450.
Please send your forms to:
Yuba County Environmental Health
915 8th Street, Suite 123
Marysville, CA 95901
MEDICAL WASTE GENERATOR APPLICATION QUESTIONNAIRE
Please check the appropriate response for the questions below.
1.
Does your business or service generate any of
the medical wastes listed below?
yes [ ]
no [ ]
If your answer is no, please complete the certification statement (page 2) and return it to the
address indicated. You do not need to complete the remainder of this questionnaire.
If your answer is yes, please check the type(s) of waste listed below that you or your facility
generate. Please complete the rest of this questionnaire.
[ ]
Laboratory wastes - specimen of microbiologic cultures, stocks of infectious agents, live and
attenuated vaccines, and culture mediums
[ ]
Blood and/or body fluids - liquid blood elements or other regulated body fluids, or articles
contaminated with blood or body fluids
[ ]
Sharps - syringes, needles, blades, broken glass
[ ]
Contaminated animals - animal carcasses, body parts, bedding materials
[ ]
Surgical specimens - human or animal parts or tissues removed surgically or by autopsy
[ ]
Isolation waste - waste contaminated with excretion, exudate, or secretions from humans or
animals who are isolated due only to highly communicable diseases listed by Centers for
Disease Control as requiring Biosafety level 4 precautions.*
2.
Do you generate 200 or more pounds per month
of the types of medical waste listed above?
yes [ ]
no [ ]
3.
Do you plan to treat your medical waste on-site,
that is at your facility, by autoclaving,
incinerating or using microwave technology?
yes [ ]
no [ ]
4.
If you generate less than 80 pounds of medical
waste per month, do you want to apply for a
Limited Quantity Hauling Exemption? This
exemption allows you or your staff to
transport medical waste yourselves, without
hiring a registered hazardous waste hauler,
to a medical waste treatment facility or
transfer station.
yes [ ]
no [ ]
If your answers to questions 2, 3, and 4 are no, then complete pages two and three. Return
completed forms and fees to:
YUBA COUNTY ENVIRONMENTAL HEALTH
915 8TH STREET, SUITE 123
MARYSVILLE, CA 95901
*Biosafety Level 4 viruses and diseases are: Congo-Crimean hemorrhagic fever, Tick-borne encephalitis virus
complex (Absettarov, Hanzalova, Hypr, Kumlinge, Kyasanur Forest disease, Omsk hemorrhagic fever, and
Russian Spring-Summer encephalitis), Marburg disease, Ebola, Junin virus, Lassa fever virus, Machupo virus.
Page One
CERTIFICATION FOR NON MEDICAL WASTE GENERATORS
AND MEDICAL WASTE GENERATORS
NOT REQUIRED TO REGISTER
Please indicate the appropriate statement.
[ ]
I declare under penalty of law that to the best of my knowledge and belief I do not generate, store,
or treat any of the wastes specified on the Pre-Application Questionnaire as Regulated Medical
Wastes.
[ ]
I declare under penalty of law that I will not be treating regulated medical waste at my facility by
means of autoclaving, incinerating or micro waving nor will I or my staff be transporting
untreated medical waste without the use of a registered hazardous waste hauler.
BUSINESS NAME:
BUSINESS ADDRESS:
STREET
CITY
STATE
COUNTY
ZIP
TELEPHONE (
)
NAME OF RESPONSIBLE PERSON
SIGNATURE
DATE
Do you share a common storage facility for storing/disposing of medical wastes with other medical
offices? Yes [ ] No [ ] If yes, what is the name and address of the medical offices property owner?
Name
Telephone Number (
Address
City
Please return this certification to:
Yuba County Environmental Health
915 8th Street, Suite 123
Marysville, CA 95901
(530) 741-6251
Page Two
)
MEDICAL WASTE SMALL QUANTITY GENERATOR
EXEMPTION INFORMATION DOCUMENT
Pursuant to the Medical Waste Management Act (California Health & Safety Code, Division 20,
Chapter 6.1) Small Quantity Generators are required to maintain informational documents
regarding how the facility handles medical waste as well as all tracking documents and receipts
for medical waste transported off-site for treatment and disposal for a period not less than 2
years.
To grant your facility a Small Quantity Generator Exemption please complete the below
information or provide your own informational document as to how medical waste is handled in
your facility.
Facility Name:
Method of on-site storage:
Average expected storage time:
Method of disposal:
Name of Medical Waste Hauler:
Other Comments:
Page Three