AppendixI.

>

This appendix describes each section (box) of the biomedical waste tracking form and provides mandatory instructions for completing each of these sections. The generator shall complete Boxes 1–15, the transporter shall complete Boxes 16–21, and the operator of the solid waste facility shall complete Boxes 22–23. The transporter may assist the generator in completing any of the boxes, but the generator is responsible for ensuring the accuracy of information entered on the form and must sign Box 15 after Boxes 1–14 are completed.

Box 1. Generator’s Name and Mailing Address. Enter the name and mailing address of the generator. The mailing address shall be the address to which the solid waste facility will return the signed copy of the tracking form, and should be for the location where the generator’s tracking forms will be handled for purposes of recordkeeping and exception reporting (e.g., the company’s billing office, corporate headquarters, or the actual site of generation).

While the address entered here need not identify the particular site of generation, the generator shall maintain his records so that individual waste shipments (identified by a unique tracking form number assigned by the generator, discussed next) can be associated with the actual sites of generation.

Box 2. Tracking Form Number. This is the unique number that the generator shall assign to each shipment of biomedical waste. It will ensure that each individual shipment can be identified and independently tracked from the site of generation. (The number may be the date of shipment or some other notation that the generator wishes to utilize.)

Box 3. Generator Telephone Number. Enter the telephone number of a contact person for the generator who can provide additional information about the shipment in the event of an emergency or in the event that the transporter or solid waste facility requires it for other reasons (e.g., to inform the generator that an alternative waste disposal facility must be used).

Box 4. State Generator Permit or ID Number. This box is not applicable under current state law and should be left blank.

Box 5. Transporter’s Name, Mailing Address and U.S. Environmental Protection Agency ("EPA") Medical Waste Identification Number. Indicate in this space the name and address of the transporter who will be the first transporter of the biomedical waste which is the subject of the tracking form. The address shall be the business mailing address of the transporter. The transporter shall fill in his EPA Medical Waste Identification Number for the State in which the waste was generated. If a number has not yet been assigned, the transporter shall leave this box blank. The EPA Medical Waste Identification Number is assigned by EPA when the transporter notifies EPA.

Box 6. Transporter Telephone Number. Enter the telephone number of the transporter that the generator or solid waste facility operator may call to obtain information regarding a biomedical waste shipment.

Box 7. State Transporter Permit or ID Number. Enter the biomedical waste transporter permit number issued to transporter pursuant to subsection (g) of this section.

Box 8. Solid Waste Facility Name and Address. Enter the name and site address of the solid waste facility to which the biomedical waste is to be delivered. The site address is necessary to inform the transporter where the waste must be delivered. (If the generator does not have this information, the transporter may complete this section, but only before the generator signs the form. Transfer stations and other temporary storage facilities used by transporters for storage of waste during transport shall not be listed here as the solid waste facility.)

Box 9. Solid Waste Facility Telephone Number. Enter the solid waste facility’s telephone number which a generator or transporter may call to obtain information regarding a biomedical waste shipment.

Box 10. State Solid Waste Facility Permit or ID Number. Enter the solid waste facility permit number assigned by Department of Environmental Protection pursuant to Section 22a-208a of the General Statutes. If the solid waste facility is located outside Connecticut, enter the facility permit or other identification number assigned by the State in which the facility is located.

Box 11. U.S. Environmental Protection Agency Waste Description. In Box 11 (A), indicate untreated biomedical waste. In Box 11 (B), indicate decontaminated biomedical waste. In Box 11 (C), indicate chemotherapy waste. The generator shall determine and indicate the type(s) of his waste before completing Boxes 12 and 13.

Box 12. Total Number of Containers. Enter the total number of containers (e.g., bags, boxes, pails, drums, etc.) for each applicable waste type in the corresponding space.

Box 13. Total Weight or Volume. Enter the total weight of the waste, by applicable waste type, in the corresponding space. If the waste is oversized and is not packaged in a standard container, a volumetric measure may be used; however, the unit of measure shall be noted in that space as well.

Box 14. Special Handling Instructions and Additional Information. Generators may use this space to indicate special transportation, treatment, storage, or disposal information or bill of lading information, including alternative treatment and/or disposal facility information, if necessary. Generators may also include in this box a written request for the solid waste facility to certify disposal of the waste through signature and dating within this box. (Note: The signature in the solid waste facility Certification Box (Box 22) is only to be used to acknowledge receipt of the waste at the time of delivery to the facility.)

For out-of-State shipments, generators shall enter in this space the point of departure (city and State) for those wastes destined for facilities outside of Connecticut. This space may also be used if there is need to identify a third transporter.

This space should also be used to provide special instructions or additional information regarding oversized biomedical waste that cannot be easily packaged in plastic bags or standard containers. In these instances, enter a description of the waste, including whether the waste is untreated or decontaminated, the number of pieces, and the approximate total weight.

Box 15. Generator’s Certification. This statement, when signed by the generator, certifies that (i) all information required to be provided by that generator is accurate (including any information provided by the transporter in Boxes 1–14), (ii) all wastes indicated on the tracking form are properly prepared for transport, and (iii) all applicable State and Federal requirements have been met. The generator shall enter his name into this statement and read it, sign it by hand, and date it. The individual signing the statement must be authorized in writing to make the required declarations by the generator.

Box 16. Transporter 1 Certification of Receipt. The first transporter shall acknowledge acceptance of a biomedical waste shipment from the generator by signing the form in this box and recording the date of acceptance. Before doing so, a transporter shall indicate in Box 23 of the tracking form any circumstances of the type described in subparagraph (h) (20) (A) of this section. In those instances when a transporter initiates a tracking form, he shall complete Boxes 1–15 and if he is also the first transporter as identified in Box 5 (Transporter’s Name and Mailing Address), he shall acknowledge receipt as transporter 1.

Box 17. Transporter 2 Name, Address, and U.S. Environmental Protection Agency Medical Waste Identification Number. In the event the waste shipment is to be transported by a second transporter, such second transporter shall enter in this box his name and business mailing address and his U.S. Environmental Protection Agency Medical Waste Identification Number if it is available.

Box 18. Transporter 2 Telephone Number. Enter the second transporter’s telephone number to be used when checking or investigating the status of a shipment.

Box 19. Transporter 2 State Transporter Permit or ID Number. In this box, a second transporter shall enter his biomedical waste transporter permit number assigned under subsection (g) of this section, or, if such second transporter is an out-of-state transporter, he shall enter any permit or other identification number assigned to him by such other state.

Box 20. Transporter 2 or Intermediate Handler Certification of Receipt. A second transporter shall acknowledge acceptance of the waste shipment by entering his name and the date of acceptance and signing the form. Before doing so, he shall indicate in Box 23 of the tracking form any circumstances of the type described in subparagraph (h) (20) (A) of this section.

Box 21. New Tracking Form Number. If a biomedical waste transporter consolidates multiple biomedical shipments on a new tracking form, a new tracking form number shall be recorded in this box on the original generator’s form.

Box 22. Solid Waste Facility. The operator of a solid waste facility shall acknowledge acceptance of biomedical waste by printing or typing his name and date of acceptance and signing in this box. Before doing so, he shall complete Box 23, as applicable, or, if there is nothing to record in Box 23, he shall place a check next to the statement "received in accordance with items 11, 12 and thirteen."

If biomedical waste is delivered to a solid waste facility other than that indicated in Box 8, the operator of the solid waste facility that accepted the waste shall complete Box 22 in the manner described in the foregoing paragraph and shall type or print his address, telephone number, and permit number assigned pursuant to Section 22a-208a of the General Statutes.

Box 23. Discrepancy Box. In Box 23 the operator of the solid waste facility shall indicate any circumstances of the type described in subparagraph (h) (20) (A) of this section. (Note: In some instances, due to the consolidation provisions of subdivisions (h) (18) and (19) of this section, transporters may also need to complete this box.)

(Effective March 21, 1990)