HomeMy WebLinkAboutmedical-waste-small-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
SMALL QUANTITY MEDICAL WASTE GENERATOR REGISTRATION/PERMIT APPLICATION FORM
Pursuant to Division 104, Part 14, California Health and Safety Code, California Medical Waste Management Act, all generators of medical/biohazardous waste in Alameda County must register with the local enforcement agency, Alameda County Department of Environmental Health (DEH). Facilities that generate less than 200 pounds of medical waste per month are categorized as Small Quantity Generators (SQG). If this facility generates more than or equal to
200 pounds of medical/biohazardous waste per month, in any month of the year, this facility would be categorized as a Large Quantity Generator (LQG) and will need to register with DEH using a separate form (Medical Waste Generator
Registration Form). If your facility does NOT generate any medical/biohazardous waste, please complete this from and sign the “Certification for Non-Medical Waste Generators” statement located on the back of this form.
FACILITY INFORMATION
Facility Name: Facility Owner:
Facility Address: City / Zip:
Mailing Address: City / Zip:
Contact Person: Phone: Email Address:
PART I.
Generation of Medical Waste – Complete the section below. If you do not generate medical waste in Alameda County, skip to Part II below.
Types of Medical Wastes Generated Pounds/Month Average
pounds any single
Fluid Blood Products (This includes dressings, containers or equipment containing fluid blood, fluid blood products, or blood from animals known to be
Laboratory Wastes (Specimen or biologic cultures, stocks of infectious agents, live and attenuated vaccines, 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)
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Isolation Wastes (Wastes contaminated with excretion, exudates or from animals infected and isolated due to the highly communicable diseases as listed by the
Trace Chemotherapeutic Wastes (Gloves, gowns, towels and I.V. solutions bags and empty tubing, etc. contaminated with trace amounts of chemotherapeutic
Pharmaceutical Wastes (Outdated, unused California-only regulated pharmaceuticals)
Name and Address of Registered Medical/Biohazardous Waste Transporter/Mail-Back System: (Required Field)
Name:
Address:
CHOOSE ONE OF THE FOLLOWING GENERATOR TYPES: (Check all that apply)
Small Quantity Generator (Generating less than 200 pounds of medical/biohazardous waste in any month within the last calendar year)
With Onsite Treatment
With NO Onsite Treatment
Materials of Trade Exemption/Limited Quantity Hauling Exemption (Transports medical waste generated in limited quantities up to 35.2 lbs. to the central location of accumulation). NOTE: Must register with Alameda County DEH as a Small Quantity or Large Quantity Generator
Common Storage Facility (Provide a list of generators that this Common Storage Facility serves. Add an additional sheet for more generators). Number of generators served:
I declare under penalty of law that to the best of my knowledge, the statements made herein are correct and true. Print Name: Title:
Signature: Date:
PART II.
As defined by the Medical Waste Management Act Section 117690, I declare under penalty of law that to the best of my knowledge that this facility does not generate, store, or treat any of the wastes specified in Part I as regulated medical
wastes in Alameda County.
Print Name:
Signature: Date:
FOR OFFICIAL USE ONLY Page 2 of 2 August 2021
FA# PR# AMOUNT PAID: DATE PAID:
ENVIRONMENTAL HEALTH SPECIALIST:
APPROVED NOT APPROVED DATE: