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Medical Waste Closure Plan
Revised October 2019
Phone: (510) 567-6790 Fax: (510) 337-9234
MEDICAL WASTE FACILITY CLOSURE PLAN
Required to be submitted for the termination of treatment at Small Quantity Generators
[H&S, Section 117935(j)] and Large Quantity Generators [H&S, Section 117960(j)]
Please submit within 30 days prior to facility closure.
FACILITY/CONTACT INFORMATION
Facility Name: _____________________________________________________________________
Address: __________________________________________________________________________
Suite or Unit: _________________ City: _____________________ State: _______ ZIP: ___________
Primary Contact: __________________________________ Title: _____________________________
Email: __________________________________________ Phone: ___________________________
Secondary Contact: _______________________________ Title: _____________________________
Email: __________________________________________ Phone: ___________________________
PROPOSED SCHEDULE OF CLOSURE
Proposed Start Date: ________________________ Duration of Closure: _______________________
Proposed Move Out Date: ______________________ ☐ N/A
TYPES OF MEDICAL WASTE GENERATED
□ Biohazardous (Red bag) ☐ Sharps ☐ Pathology ☐ Trace Chemotherapeutic Waste
□ Pharmaceutical Waste
Does this closure involve a vivarium or an animal care facility? ☐ Yes ☐ No
DECONTAMINATION PROCESS
What sanitizing agent will you be utilizing? □ Hypochlorite solution (500 ppm available chlorine) ☐ Phenolic solution (500 ppm active agent) □ Quaternary ammonium solution (400 ppm active agent) □ Hot water of at least 82°C (180°F) for a minimum of 15 seconds □ Iodoform solution (100 ppm available iodine)
□ Other (describe): ________________________________________________________________
PERSONNEL
Who will be performing the decontamination and closure activities?
□ Facility staff ☐ Contractor ☐ Other (list): ___________________________________________
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Medical Waste Closure Plan
Do you have a written Health and Safety plan for this closure? ☐ Yes (please attach) ☐ No ☐ N/A
DISPOSAL
Provide a copy of the last medical waste tracking document to the Local Enforcement Agency (LEA).
__________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
□ I hereby certify that the submitted information is true, accurate, and complete. I understand that before any changes are made to this document, I must notify the Local Enforcement Agency (LEA).
Signature of Owner/Agent or Representative: _____________________________ Date:___________
OFFICIAL USE ONLY
Date received: ____________ ☐ Approved ☐ Approved with changes: _________________________
Additional requirements: ______________________________________________________________
Environmental Health Specialist signature: _______________________________ Date: ___________