HomeMy WebLinkAboutmedical-waste-program-temporary-offsite-event-notification-formAlameda 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 PROGRAM TEMPORARY OFFSITE EVENT NOTIFICATION FORM
Event Name:
Address:
City: State: Zip Code:
Phone: Email Address:
Contact Person: Event Organizer MW Generator
Vaccination Clinic Blood Drive Stand Down Event Health FairEvent Type: COVID Testing Other:
(Check all that apply) Specify if other:
Event Date(s):
PARTICIPATING MEDICAL WASTE (MW) GENERATOR FACILITY INFORMATION (NOTE: If more than one facility, please use a separate form for each MW generator)
FA# PR#
Medical Waste Generator Facility Name:
Address: City: State: Zip Code:
Phone: Email Address:
Contact Person:
REGISTERED MEDICAL / BIOHAZARDOUS WASTE TRANSPORTER
Transporter Name: Address: Phone Number:
Provide a short description on how medical wastes generated (e.g. sharps, etc.) will be stored at the event site and transported offsite.
TEMPORARY OFFSITE EVENT FILING FEE INFORMATION
Alameda County Department of Environmental Health (DEH). NOTE: Small and Large Quantity Generators already registered and/or permitted with Alameda County DEH are not required to pay additional temporary offsite event
SIGNATURE
Self-Declaration: I certify that the above information is complete & correct to the best of my knowledge.
Signature: Date:
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Alameda 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
Instructions for the Applicant:
• Complete the Medical Waste Program Temporary Offsite Event Notification Form. NOTE: A separate completed form is required to be submitted for each event application.
• Mail, email (dehsolidwaste@acgov.org), or submit in person the completed form to: Alameda County Department of Environmental Health
Solid/Medical Waste Management 1131 Harbor Bay Parkway Alameda, CA 94502
• Submit a payment along with each completed application. NOTE: Small and Large Quantity Generators already registered and/or permitted with Alameda County DEH are not required to pay additional temporary offsite event registration and/or permit fees but are required to submit the Temporary Offsite Event Notification Form.
• Keep a copy of the completed notification form(s) for your records and make them available for review by regulatory personnel during your facility’s or temporary event(s) inspections.
• For assistance in completing your notification form, please contact a Medical Waste Program staff member at (510) 567 – 6790.
FOR OFFICIAL USE ONLY
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FA# PR# AMOUNT PAID: DATE PAID:
ENVIRONMENTAL HEALTH SPECIALIST:
APPROVED NOT APPROVED DATE: