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Home My WebLink Aboutmedical-waste-large-quantity-generator-registration-application-form-2Alameda County Department of Environmental Health Solid/Medical Waste Management 1131 Harbor Bay Parkway, Alameda, CA. 94502 Phone: (510)567-6790 Fax: (510) 337-9234 https://deh.acgov.org/index.page MEDICAL WASTE GENERATOR REGISTRATION APPLICATION FORM WHO IS REQUIRED TO REGISTER? Each Large Quantity Generator (LQG) shall register with the enforcement agency pursuant to the California Health and Safety Code, Division 104, Part 14, California Medical Waste Management Act ([H&SC § 117950(a)]. The Large Quantity Generator (LQG) registration is valid for one year [H&SC § 117970(b)]. Facilities that generate equal to or more than 200 pounds in any month of the year of medical/biohazardous waste are categorized as Large Quantity Generators (LQG). A medical waste Common Storage Facility that collects the accumulated waste of more than one medical waste generator shall be registered with the enforcement agency (H&SC § 117908). Each Small Quantity Generator (SQG) using on-site treatment such as steam sterilization shall register with the enforcement agency [H&SC § 117925(a)]. To register, complete this form and submit to Alameda County Department of Environmental Health, Office of Solid/Medical Waste Management. Type of Application:  New Registration/Permit  Renewal  Change of Ownership I. FACILITY INFORMATION Facility Name: Facility Owner: Facility Address: City/Zip: Mailing Address: City/Zip: Contact Person: Phone: Email Address: Fax: II. GENERATOR CATEGORIES REQUIRING REGISTRATION (Please check all that apply) Please indicate the category of medical waste generator that best describes your facility.  Large Quantity Generator with NO Onsite Treatment – This facility generates 200 pounds or more of medical/biohazardous waste in any month of a 12-month period and medical waste is NOT treated onsite.  Large Quantity Generator with Onsite Treatment – This facility is a LQG and medical/biohazardous waste is treated at this facility  Small Quantity Generator with Onsite Treatment – This facility generates less than 200 pounds of medical waste per month in every 12-month period and medical/biohazardous waste is treated at this facility  Common Storage Facility – This office building/complex/facility operates an area designated for the storage of medical/biohazardous waste. This area is shared by multiple independently operated SQGs. The medical waste is transported offsite by a registered medical waste hauler. (Provide a list of generators that this Common Storage Facility serves. Add an additional sheet for more generators). Number of generators served: GENERATOR NAME ADDRESS PHONE NUMBER Page 1 of 3 III. TYPES OF MEDICAL/BIOHAZARDOUS WASTES GENERATED (Please check all that apply) Please indicate the type(s) of medical waste generated by this facility:  Fluid Blood Products (This includes dressings, containers or equipment containing fluid blood, fluid blood products, or blood form animals known to be infected with diseases which are highly communicable to humans)  Laboratory Wastes (Specimen or biologic cultures, stocks of infectious agents, live and attenuated vaccines and culture mediums, test tubes, vacuum tubes)  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 Wastes (Wastes contaminated with excretion, exudates or from animals infected and isolated due to the highly communicable diseases listed by the Centers for Disease Control)  Trace Chemotherapeutic Wastes (Gloves, gowns, towels, and I.V. solutions bags and empty tubing, etc. contaminated with trace amounts of chemotherapeutic agents)  Pharmaceutical Wastes (Outdated, unused California-only regulated pharmaceuticals)  Other (Please specify) IV. QUANTITY OF MEDICAL/BIOHAZARDOUS WASTES GENERATED This facility generates this amount of regulated medical waste per month: lbs. V. OUR WASTE IS: (Please check all that apply)  Picked up by a registered transporter; name and address: • Refer to California Dept. of Public Health’s website for a list of authorized haulers: https://www.cdph.ca.gov/Programs/CEH/DRSEM/Pages/EMB/MedicalWaste/Transporters.aspx  Mailed via Mail-Back System; name:  Treated onsite by autoclave or by alternative treatment method VI. NAME AND ADDRESS OF TREATMENT/DISPOSAL FACILITY: If medical waste is disposed of or treated offsite, provide the following information: Type of waste(s) (See Section III): 1. Name and address of registered Hazardous/Medical Waste Hauler: 2. Name and address of Treatment/Disposal Facility: Page 2 of 3 VII. MEDICAL WASTE MANAGEMENT PLAN (Please check all that apply) All generators required to register must have on file with the enforcement agency a current Medical Waste Management Plan. The Medical Waste Management Plan shall include an Emergency Action Plan, which delineates the procedures for properly handling on-site spills and releases of medical waste (H&SC §117943). The Emergency Action Plan should address surface cleanup, protective clothing, and equipment to be used, and disinfecting procedures. The Medical Waste Management Plan must be updated as facility operations or personnel information changes occur. Please indicate the status of your Medical Waste Management Plan:  A review of the Medical Waste Management Plan previously submitted to Alameda County DEH was conducted and it was determined that a plan update is not required.  The Medical Waste Management Plan has been updated and is attached.  An approved Medical Waste Management Plan will be submitted to the Alameda County DEH with the Certificate of Return to Compliance from the last onsite inspection. VIII. CERTIFICATION I declare under penalty of law that to the best of my knowledge, the statements made herein are correct and true. Authorized Representative: Print Name: Title: Signature: Date: The fee page is available on our website at https://deh.acgov.org/solidwaste/medical-waste.page. Make the check payable to Alameda County Department of Environmental Health. For other forms of payment, please refer to our website at https://deh.acgov.org/billing-fees-permits.page. Mail the application and fee to: Alameda County Department of Environmental Health 1131 Harbor Bay Parkway Alameda, CA 94502 FOR OFFICIAL USE ONLY Page 3 of 3 FA# PR# AMOUNT PAID: DATE PAID: ENVIRONMENTAL HEALTH SPECIALIST:  APPROVED  NOT APPROVED DATE: