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ADoc-108194

Application Document
Name ADoc-108194 Owner Brian Speer
Application A-153606 Internal Comments
Document Name 1) Facility Map(s) 2) Legal Description 3)
R315-313-2/R315-313-3 Site Standards
4) R315-302-2 Plan of Operation 5) or
Additional documents as necessary
External Comments
Status Submitted Link to gdrive file Click here
Application
Recordtype Solid_Waste Document Type
Gdrive file id 1kOktfhyE-
DoJu9xbqWBWJXHQrQtAYtos

Application Report
Account Trilogy MedWaste West, LLC
Created By Valentina Vreugdenhil, 7/29/2024, 2:04
PM
Last Modified By Valentina Vreugdenhil, 7/29/2024, 2:16
PM
Files
280__SOP_V1R1-2024.07.23
Last Modified 7/29/2024, 2:16 PM
Created By Valentina Vreugdenhil

Copyright © 2000-2025 salesforce.com, inc. All rights reserved.
4/23/25, 3:18 PM ADoc-108194 ~ Salesforce - Unlimited Edition
https://utahdeqorg.my.salesforce.com/a033d000002LQr0AAG/p 1/1
STANDARD OPERATIONS PLAN
Medical Waste Transfer Facility
TMW Salt Lake City - 280
2500 S. Decker Lake Blvd #12
West Valley, UT 84119
Table of Contents
1) INTRODUCTION ........................................................................................................................................ 1
2) OPERATIONS ............................................................................................................................................ 1
A) SERVICE .................................................................................................................................................... 2
B) MEDICALWASTETRANSPORT ................................................................................................................. 2
C) UNACCEPTABLEWASTE ........................................................................................................................... 4
D) CONTAINERUNLOADING ANDHANDLING .............................................................................................. 5
E) TREATMENTCARTLOADING (MANUAL AND HYDRAULIC DUMPERS) .............................................................. 7
F) CONTAINERDISINFECTION...................................................................................................................... 7
G) LOADINGANDUNLOADINGAUTOCLAVE................................................................................................ 8
H) STERILIZATIONPROCESS .......................................................................................................................... 8
I) POSTTREATMENT .................................................................................................................................... 8
J) EMERGENCY SHUTDOWN ........................................................................................................................ 9
K) HOURSOFOPERATION............................................................................................................................ 9
3) ACCESS CONTROL..................................................................................................................................... 9
4) TREATMENT/STORAGE AND CAPACITY LIMITS ....................................................................................... 10
5) EQUIPMENT MAINTENANCE .................................................................................................................. 10
A) PREVENTATIVEMAINTENANCE ............................................................................................................. 10
B) PERIODIC INSPECTIONS (STEAM STERILIZERAND BOILER) ................................................................... 11
C) GENERALINSPECTION AND MAINTENANCE ......................................................................................... 11
D) ROUTINE MAINTENANCE ....................................................................................................................... 11
E) DAILYMAINTENANCE(STARTOFSHIFT): .............................................................................................. 12
F) WEEKLYMAINTENANCE: ....................................................................................................................... 12
G) QUARTERLYMAINTENANCE: ................................................................................................................. 12
H) INSPECTION SCHEDULE .......................................................................................................................... 13
7) FIRE RESPONSE EQUIPMENT .................................................................................................................. 13
8) TRAINING PROGRAM ............................................................................................................................. 13
9) RECORD KEEPING ................................................................................................................................... 15
A) REPORTS FOR TREATMENT EQUIPMENT OPERATION .......................................................................................... 15
B) REPORT FOR TRANSPORTATION OPERATIONS ..................................................................................................15
10) HOUSEKEEPING ...................................................................................................................................... 16
11) COMMUNICATION ................................................................................................................................. 17
CONTACT INFORMATION ..................................................................................................................................... 17
Attachment Listing
Attachment 1 – Exposure Control Plan
Attachment 2 – Waste Acceptance Protocol
Attachment 3 – Radiation Screening Protocol
Attachment 4 – Truck Loading and Unloading
Attachment 5 – Exhibit C- Spill Response
Attachment 6 – Washing Containers
Attachment 7 – Emergency Action Plan
Attachment 8 – Autoclave Operation SOP
Attachment 9 – Boiler Operation SOP
Attachment 10- Daily Housekeeping List
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1) INTRODUCTION
Trilogy MedWaste Southeast, LLC (Trilogy) operates a Medical Waste Treatment Facility located
at 2500 S. Decker Lake Blvd. West Valley, UT. The site is properly zoned with sanitary sewer and
natural gas service. The site is properly suited for medical waste treatment and transfer operations.
The facility is designed to accommodate two (2) steam sterilization (autoclave) units. Treated
waste is transferred into a compactor prior to being transported to a permitted Sub-Title D landfill.
Operation of this solid waste management facility shall be in accordance with the R315-312 or
R315-313 of the Utah Solid Waste Permitting and Management Rules and the Utah Solid and
Hazardous Waste Act (UCA 19-6-101 through 123), the conditions contained in this permit; and
this approved operating plan. Should the approved plan and the rules conflict, the Solid Waste
Management Rules shall take precedence unless specifically addressed by permit condition.
Failure to comply may result in compliance action or permit revocation.
2) OPERATIONS
Trilogy accepts infectious waste as defined in Utah Administrative Code (UAC) R315-316 also
known as medical waste. Medical waste is in prepackaged boxes, reusable and disposable
containers of various sizes. In addition, reusable and disposable sharps containers of various sizes
are also utilized. The waste is treated via an autoclave utilizing steam. The treated medical waste
will be disposed of in a permitted Sub-Title D landfill.
Only Non-Hazardous, Non-RCRA pharmaceutical waste will be accepted for treatment. The
generator is responsible for maintaining a comprehensive formulary. The generator classifies the
non-hazardous pharmaceutical waste based on the generator’s formulary. The Active
Pharmaceutical Ingredients (AIPs) would be non-hazardous.
Medical Wastes requiring incineration will be transferred to a permitted incinerator capable of
treating bypass waste (Pathological Waste and Trace Chemotherapy Waste).
All medical waste containers will be handled in accordance with OSHA’s Blood Borne Pathogen
regulations.
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Refer to Attachment 1 – Exposure Control Plan.
Medical Waste is collected from generators and transported to the treatment facility. Medical
Waste will also be received from 3rd Party licensed transporters. Hazardous (RCRA) Waste will
not be accepted.
a) SERVICE
Trilogy MedWaste provides collection and/or treatment services to the healthcare industry in
this region. The service usually includes providing containers and other necessary supplies for
proper packaging of the waste materials along with barcode labels for transport and tracking.
Proper packaging includes using only approved red bags and approved reusable containers,
cardboard boxes, tape, and labels. Boxes that are not packaged properly will not be picked up
including weighing over 50 pounds, boxes that are crushed, torn or distorted in any way, label
not attached (name and address correct), or not completely taped shut on the top and bottom.
Any nonconforming boxes must be repackaged before picked up for transport.
b) MEDICAL WASTE TRANSPORT
Prior to leaving the facility, the driver will check his daily route sheet to assure that all pickups
are scheduled and to plan his course of efficient routing. The driver will also obtain all
necessary documents (manifests, reports, etc.) to be delivered to customers. While reviewing
their daily schedule, the driver makes notes of the supplies that they may need to deliver to the
customers. The driver will perform a vehicle inspection according to OSHA and DOT
regulations.
Medical waste will be transported in trucks by employees of Trilogy MedWaste West, LLC,
contract drivers for Trilogy MedWaste West, LLC and other waste transporters. Medical Waste
may also come to the facility through the mail back program shipped through a common
carrier. Medical waste is shipped to the facility in approved corrugated boxes, reusable
containers, or other disposable containers. Trilogy MedWaste will not transport, or accept for
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transport, waste that is not properly packaged or classified in accordance with Utah Division
of Waste Management Solid Waste Program.
Trilogy MedWaste shall also maintain compliance with the requirements of Utah Infectious
Waste Management Guidance which includes:
Transport infectious waste separate from other waste unless the waste is contained in a
separate, fully enclosed leak-proof container within the vehicle compartment or unless
all of the waste in the vehicle is to be treated as infectious waste. Vehicles transporting
infectious waste must meet all requirements of the Department of Transportation.
Transport infectious waste using equipment that will contain all waste so that there are
no releases of infectious waste to the environment and follow USDOT requirements.
Provide training for drivers in waste handling and spill cleanup methods.
Label vehicles by DOT standards.
Have spill kit available.
Clean all surfaces of transport vehicles when spills have occurred.
Store waste no longer than 7 days without refrigeration and no longer than 60 day total.
All biomedical waste picked up by Trilogy MedWaste are pre-packaged by the customer at the
customer's facility prior to loading into the truck. A biomedical waste manifest tracking form
is completed for each pickup and signed by the customer acknowledging proper segregation
and packaging.
Prior to moving any containers from the customer's storage area to the vehicle for loading, the
driver will inspect each container to verify that it meets the following conditions:
Each container must not be damaged (crushed, cut, bent, or leaking).
Each container must be in an upright position.
Any improperly packaged containers will be reported to the customer for repackaging.
Trilogy MedWaste West employees will not assist in the packing procedures.
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Once all containers are inspected, the driver will transport them to the vehicle using any method
that will not damage or tip the containers.
When loading containers into a Trilogy MedWaste vehicle, each medical waste container
received from a customer will be marked or labeled on the outer surface as follows. Trilogy
MedWaste barcode label provided to customers contains all the information.
the generator’s name, address, and telephone number
the transporter’s name, address, and telephone number
storage facility name, address, and telephone number, when applicable
treatment facility name, address, and telephone number
date of shipment
“INFECTIOUS WASTE” or “BIOMEDICAL WASTE” or “BIOHAZARD”
The driver will then complete the waste manifest, obtain an authorized customer representative
signature, and leave a copy with the customer. Prior to departing the customer's premises, the
driver will re-inspect the containers to ensure they are properly stacked, not damaged, and
show no visible signs of leakage. The driver will then update his route sheet and continue to
his next stop or return to the Trilogy MedWaste facility.
When all containers are properly marked and coded, the driver will stack the containers across
the interior of the vehicle body using care not to damage or tip the containers. Each row of
containers is secured using cargo retaining straps to prevent tipping. The driver will lock the
vehicle upon completion of loading at each customer location.
If transfer or storage operations cease in the Utah facility, Trilogy MedWaste will implement
the contingency plan and move and treat all waste at other Trilogy MedWaste West facilities.
c) UNACCEPTABLE WASTE
Properly classified waste materials, which are received at the facility, but cannot be processed
by steam sterilization (Bypass Waste), are segregated, and staged for further transport to an
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alternate facility. Waste containers are packaged and sealed by the generator prior to pick up
by Trilogy MedWaste drivers. Due to the nature of biomedical waste, health hazards preclude
all Trilogy MedWaste personnel from opening boxes or cartons of waste prior to dumping into
the treatment carts at the facility.
Unacceptable waste received is returned to the generator, as soon as practical, or is transferred
to an appropriate disposal facility. Shipping documents are utilized to track this material to the
proper treatment and disposal facility. Hazardous and radioactive wastes shall not be received
through the medical waste management program.
Refer to Attachment 2 – Waste Acceptance Protocol.
To respond to the concerns relative to the presence of radioactive materials in the waste loads,
radiation detectors are mounted over each dock receiving door which gives an alarm upon the
detection of radioactive substances in the load. The radioactive waste will be located and
returned to the generator or picked up by an approved transporter.
Refer to Attachment 3 – Radiation Screening Protocol.
d) CONTAINER UNLOADING AND HANDLING
Infectious waste shall be transported and stored in a manner that prevents exposure to the
environment and inclement weather. Vehicles containing untreated waste will enter the facility
and approach a designated parking area or dock door determined by the shift operator. Vehicle
traffic will pass through a designated gate gaining access to the loading and unloading area.
All vehicles carrying untreated waste will enter the facility through the same gate to the
property.
Upon arrival at the treatment facility the driver will report to the transportation manager or
shift supervisor on duty. The vehicle will be unloaded under the direction of the shift
supervisor.
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While unloading, the responsible shift supervisor will verify that all containers, boxes, carts,
and bins are manifested and accounted for. All required paperwork will be handed over to the
shift supervisor or the transportation manager.
Refer to Attachment 4, Truck Loading and Unloading SOP.
During the unloading, containers designated for incineration (Bypass Waste) are set aside and
put into a holding area for transport to an approved incinerator. At the time of the transfer to
an incineration facility, a new manifest is prepared for proper receipt of these materials at the
incineration facility. All waste collected will follow waste storage requirements, including
bypass and non-conforming waste. The Bypass Waste will be transferred within twenty-one
(21) calendar days from date of receipt. Pathological Waste will be stored between 35 and
45 for up to 21 days. Trace Chemo Waste will be stored for up to 30 days. Bypass Waste
will be transported to an approved facility permitted to accept the Bypass Waste. All medical
waste shall be treated within 60 calendar days of shipment from the generator.
After all biomedical waste is unloaded, the driver will complete a visual inspection of the
vehicle. All vehicles are cleaned/disinfected when visibly soiled. A medical waste spill will be
immediately contained and cleaned up.
Refer to Attachment 5, Exhibit C: Spill Response.
At the treatment facility, the transport vehicles will be moved to the unloading dock.
Employees will use hand trucks (dolly) and forklifts to unload medical waste. The dock area
will remain clear of debris and forklift accessible. Entrance into the plant from the dock is
through two roll up doors, one being 8’ wide x 12’ high, and the other 12’ wide x 12’ high.
When handling containers, all personnel in contact with containers will ensure that the utmost
care is taken to prevent damage to containers and that spills are prevented. Employees will
always wear proper protective equipment (PPE) while handling waste containers.
Refer to Attachment 2 – Exposure Control Plan
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When unloading containers or boxes at the Trilogy MedWaste facility, the plant operators will
weigh each container and record its weight with a barcode scan. The transportation personnel
will review each manifest for accountability each day of all containers and note any
discrepancies on the manifest or in the computer system to provide notes to customer service.
Packages of waste shall remain intact from the generator's site, in transit, and at the treatment
facility. There shall be no recycling efforts or intentional removal of waste from the red bags
or sharps containers prior to the waste being treated. Packaging of waste is handled in a manner
that does not impair the integrity of the packaging. Containers of waste shall not be compacted
before treatment.
e) TREATMENT CART LOADING (Manual and Hydraulic Dumpers)
After waste containers have been scanned and weighed, they are conveyed to a dumping
platform or hydraulic tipper/dumper. Disposable contents and/or the contents of the reusable
containers are then dumped into the plastic lined treatment carts.
After dumping, the reusable containers are conveyed to a container washing area where they
are cleaned with hot water and an approved disinfectant. The tipping/dumping process is
repeated until the treatment carts are full. The treatment carts are relined after each autoclave
cycle.
f) CONTAINER DISINFECTION
All reusable waste containers shall be constructed of smooth, non-porous and easily cleanable
materials that are impervious to liquids and capable of being readily maintained in sanitary
condition.
After the reusable containers are emptied, they are conveyed to the washing area where they
are cleaned with hot water and an approved disinfectant. When the cleaning operation is
completed, the containers are staged to dry. Containers are then either moved to a storage area
or loaded onto trucks for delivery to a generating facility for the collection of waste.
Refer to Attachment 6 – Washing Containers SOP
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Process water generated while cleaning reusable containers will be discharged to the sanitary
sewer system. Liquids used for cleaning operational floor, spill, or containers is drained to a
floor drain(s) which is discharged into sanitary sewer system.
Refer to Attachment 7 – Emergency Action Plan, Exhibit A – Facility Site Map for the
identified drains.
g) LOADING AND UNLOADING AUTOCLAVE
Once the treatment carts are filled with untreated medical waste, the carts are conveyed to a
staging position. Treatment carts are then loaded into the autoclave.
Once the sterilization process has been completed, the carts are staged to be emptied into a
roll-off container.
The carts are then emptied into the roll-off container by use of a forklift or other hydraulic
means. Once emptied, the treatment carts are relined with a new liner and available again for
refill with untreated medical waste.
h) STERILIZATION PROCESS
Trilogy MedWaste will use a Utah approved autoclave for sterilization. The Sterilization
treatment schedule will comply with R315-316-5 and unrefrigerated regular medical waste
shall be treated within 7 calendar days of shipment from the generator and all medical waste
shall be treated within 60 days from the same.
Refer to Attachment 8 – Autoclave Operation Standard Operating Procedure for detailed
information on every step of the sterilization process.
i) POST TREATMENT
Once the sterilization process is complete, the carts are picked up by the forklift and emptied
into the hopper of the compactor and returned to the staging area for loading medical waste.
The treated waste is stored in a roll off container not to exceed seven (7) calendar days until it
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is transported to a permitted landfill. Treated medical waste will be handled as non-infectious
solid waste according to R315-316-5 (2)(a).
Post treatment, waste shall not become putrescent. If treated medical waste becomes putrescent
Trilogy MedWaste will dispose of it within three (3) calendar days.
j) EMERGENCY SHUTDOWN
An emergency shutdown button is located on the control panel for the autoclave. Also, an
emergency shutdown button for the boiler is mounted at the exit door from the plant into the
office area.
k) HOURS OF OPERATION
The Trilogy MedWaste facility can operate 24 hours a day, 7 days a week for treatment
processing. Office hours are Monday through Friday from 8:00 AM to 5:00 PM. Independent
transporters delivering pre-manifested waste materials will be accepted by prior appointment
only.
3) ACCESS CONTROL
All doors to the facility will be locked prohibiting unauthorized entrance from the outside and
secured at all times. The main entrance to the building and office areas will be open during normal
business hours only. After hours, all doors to the facility will remain closed and locked prohibiting
unauthorized outside entry with the exception of dock doors being utilized for operations. The
entire facility is protected by a security system that will alarm when activated by an unauthorized
intruder and notify police and management.
All visitors to the facility are required to sign the visitor’s log located in the front lobby. All visitors
will be escorted. Under no circumstances will Trilogy MedWaste allow an unescorted visitor to
enter the facilities treatment area.
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4) TREATMENT/STORAGE AND CAPACITY LIMITS
Trilogy MedWaste accepts sharps/biohazard waste, trace chemotherapy waste, non-hazardous
pharmaceutical waste, and pathological waste with a total accumulation of 120,000 pounds.
Trilogy MedWaste is locally permitted to operate the treatment facility. Permitted capacity is based
on the maximum waste treatment capacities of the processing equipment, including future
additions. Each autoclave will have an estimated capacity of.12,000 pounds per day or 4.5 million
pounds per year. Only two (2) autoclaves are installed and operational with a combined estimated
capacity of 24,000 pounds per day.
The actual treatment capacity of each piece of equipment will vary based on the waste type,
density, liquid weight, handling procedures, operator interface, and efficiency protocols. Before
any future autoclaves are installed, Trilogy MedWaste will notify the appropriate state agency for
approval to do so and increase its financial assurance package as necessary.
All untreated waste is stored in a secure area located inside the facility or in enclosed, locked
transport vehicles located within the secure area of the premises to await processing. Storage of
untreated and treated waste at the facility will be based in accordance with R315-316-3, based on
the seven (7) calendar day or refrigerated time status.
Treated waste storage is maintained on the premises in a secure area awaiting transport for final
disposal.
5) EQUIPMENT MAINTENANCE
a) PREVENTATIVE MAINTENANCE
Preventative maintenance is designed as an aid in setting up a schedule of regular
inspections and checks to determine the actual condition if the equipment and to maintain
it in proper working order. The systematic use of a preventative maintenance program
may be expected to reveal any potential adverse condition in the early stages when the
remedy is relatively simple and inexpensive. This operating plan provides an overview
of the manufacturers’ Equipment Operating Manuals.
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b) PERIODIC INSPECTIONS (STEAM STERILIZER AND BOILER)
i) The treatment equipment should be kept clean at all times and special attention should
be given to the safety pressure interlock system to guard against sticking parts.
ii) Check accuracy of instruments, gauges and thermocouples. Also check relief valves to
see that they relieve at proper pressure.
iii) Make sure in-line trap drains from steam supply line to vessel are functioning properly.
Frequently inspect flanged joints and other pipe connections.
iv) Test relief valves at least once every year.
Refer to Attachment 9 – Boiler Operation SOP for daily boiler operation specifics.
c) GENERAL INSPECTION AND MAINTENANCE
The following procedures should be performed at regular intervals as indicated. This
frequency is the minimum and should be increased if usage of the autoclave demands.
Safety Valve: In accordance with the National Board of Inspections Code, periodic
checking of the safety valve operation should be performed. Periodic inspection of the
equipment by a qualified inspector is advisable. Trilogy MedWaste conducts inspections
of all pressure vessels and safety valve operation in accordance with the NC Department
of Labor, Boiler Safety Bureau.
d) ROUTINE MAINTENANCE
Prior to performing maintenance, the control switch must be turned off, facility power
to unit disconnected, and accessories must be cooled to room temperature.
Employees shall wear the proper PPE when cleaning or maintaining all equipment.
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e) DAILY MAINTENANCE (START OF SHIFT):
i) Check that supply steam pressure is in range.
ii) Check that compressed air pressure is in range.
iii) Check that water feed is open.
iv) Check door seal for nicks or abrasions, replace if necessary.
v) Check cart rollers that they are free of any debris and smooth rolling.
vi) Check that vessel interior is free of any debris and drain is clear.
f) WEEKLY MAINTENANCE:
Examine vessel and pipe insulation and covers for damage, repair if necessary.
Wipe down exterior surfaces and piping.
g) QUARTERLY MAINTENANCE:
Check, Clean, Adjust the following:
o Steam pressure regulator
o Air pressure regulator
o Vacuum pump seal water flow
o Cooling water nozzles and flow
o Main drain trap
o Vessel interior
o Control cabinet interior
o In-line filter screens
o Cart rollers
o Door latch operation
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o Calibrations, scale, thermocouple, pressure transducer (full calibration annually)
Lubricate cart wheels
Lubricate door hinge
h)INSPECTION SCHEDULE
Outside lighting will be inspected weekly and bulbs replaced as necessary.
Security gates and locks will be inspected monthly.
Warning signs will be inspected quarterly for proper visibility.
7) FIRE RESPONSE EQUIPMENT
All fire extinguishers inside the facility will be inspected monthly to check for damage, pressure
leakage and accessibility. Any damaged extinguishers will be removed from service and repaired
immediately.
Locations of fire response equipment are identified in Attachment 7 – Contingency (Emergency
Action Plan), Exhibit A: Facility Site Map.
8) TRAINING PROGRAM
Trilogy places a top priority on safety and training. The training programs for employees are
oriented towards their safety, maintenance of the equipment, and operation of the facility.
A newly hired employee will receive training before he/she is allowed to perform those specific
duties at the facility. The training will include a general orientation to Trilogy programs followed
by specific orientation to individual job functions.
The employee also takes part in a continuing training program, which includes monthly safety
meetings where they are trained on various safety topics or procedures. The supervisors also
conduct “tailgate” safety discussion periodically. All training is documented and kept in the
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employee’s training file. Additionally, general safety meetings are scheduled on a regular basis.
These meetings are used to train the employees on various safety issues which will include, but
not limited to the following:
-Tag out Procedures
Records of training will be recorded and kept electronically.
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9) RECORD KEEPING
Operating and maintenance records will be maintained for all treatment processing operations.
The plant manager is responsible for report submission in a timely manner. All waste
management records, including any documentation provided by the transporter, are maintained
for three years and made available for inspection by all regulatory agencies, along with employee
training, transportation, and equipment maintenance records.
a)Reports for treatment equipment operation
Daily log sheets
Processing records
Plant Operations weekly reports
Monthly production reports
Monthly statistical report
Monthly maintenance report
Annual Report as required
Disposal logs
Spill report (if required)
Accident report (if required)
b)Report for Transportation Operations
Vehicle condition Reports
Customer manifest for each medical waste pickup
Spill report (if required)
Accident report (if required)
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c)Report for Transferred Waste Materials
Customer list
Shipping facility waste manifests
Receiving facility waste manifests
A copy of this Standard Operations Plan is always available for review at the facility. Steam
sterilization recordkeeping will follow requirements in R315-3116-5.
10) HOUSEKEEPING
In handling medical waste, good housekeeping practices will be implemented at the facility. The
outside property will be maintained in a neat appearance by cutting and trimming the grass areas
and spraying for weed control on the property. An exterminationcontract will be in place to control
insects, vermin, etc. inside the building and around the perimeter of the building. The company
owned trucks hauling medical waste will have spill kits and PPE on board for cleaning spills and
leaks. Transporter's vehicles will be inspected, and any noticeable leaks or spills will be cleaned
and disinfected before the vehicle is released from the facility. For vehicles parked on the property,
any leaks seen emitted from the vehicle will be contained in a bucket, the source located and
removed from the vehicle. The spill will be immediately cleaned using the spill kit. Any
contamination of the ground underneath the vehicle will be removed, placed in a bag and treated
in the autoclave. The secured office area will have no carpeting (tile floors) and no contamination
will be brought into the office area. Only authorized employees will be allowed in the office area.
The plant area will be properly maintained to be clean, orderly, and well lit.
Spill cleaning materials, hospital grade disinfectants and PPE will be stored in the plant for
employees to properly clean up any spills using the required dwell times. The plant concrete floor
will be washed at least weekly, or as required for spill cleaning, into the floor drains and discharged
into the sanitary sewer. Management is trained in biohazard cleaning. The autoclave has a cleaning
cycle to maintain the inside of the autoclave chamber and the treatment carts. If any additional
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cleaning is required, the carts will be taken to the wash station where they will be pressure washed
using hot water and disinfected before being returned to service.
Refer to Attachment 10 – Daily Housekeeping List
11) COMMUNICATION
Should the treatment facility close for any reason other than normal business hours, the Company
will inform the Division of Waste Management, Solid Waste Section, upon the closing, reason for
closing and re-opening date. Additionally, prior to reopening the business, the Section will be
given notice and an opportunity to perform an inspection.
Contact Information
Name: Jace Hansen
Title: Facility Manager
Phone Number: 801-908-1045
Mobile Number: 801-201-4839
Email: [e-mail]
Mailing Address: 2500 S Decker Lake Blvd Ste 12
West Valley City UT 84119
Name: Neal Beenenga
Title: District Manager
Phone Number: 480-613-6670
Mobile Number: 480-272-4203
Email: [e-mail]
Mailing Address: 3152 N 34th Drive
Phoenix, AZ 85017
Name: Chad Plata
Title: Director of Compliance
Phone Number: 713-300-1892
Mobile Number: 713-205-7233
Email: [e-mail]
Mailing Address: 8554 Katy Free, Suite 200
Houston, Texas 77024
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Attachment 1
Attachment 12 Exposure Control Plan

Bloodborne Pathogen
Exposure Control Plan
29 CFR 1910.1030
V1R4-01.08.2024
Content
1. OBJECTIVE ......................................................................................................................... 1
2. DEFINITIONS...................................................................................................................... 1
3. BACKGROUND ................................................................................................................... 3
4. ASSIGNMENT OF RESPONSIBILITY............................................................................ 4
a. Program Administrator.................................................................................................... 4
b. Supervisors/Managers...................................................................................................... 4
c. Employees.......................................................................................................................... 4
d. Contractors........................................................................................................................ 4
5. EXPOSURE DETERMINATION....................................................................................... 5
6. METHODS OF COMPLIANCE......................................................................................... 5
a. Universal Precautions....................................................................................................... 5
b. Engineering Controls........................................................................................................ 5
c. Work Practice Controls.................................................................................................... 5
d. Personal Protective Equipment (PPE)............................................................................ 6
e. Housekeeping..................................................................................................................... 7
f. Work uniforms.................................................................................................................. 7
7. HEPATITIS B VACCINES AND POST-EXPOSURE EVALUATION AND
FOLLOW UP................................................................................................................................ 7
a. Hepatitis B Vaccine........................................................................................................... 7
b. Post-Exposure Evaluation and Follow-up...................................................................... 8
c. Information Provided to the Healthcare Professional................................................... 9
d.................................................................. 10
8. LABELS AND SIGNS........................................................................................................ 10
9. TRAINING.......................................................................................................................... 10
10. RECORDKEEPING....................................................................................................... 12
a. Medical Records.............................................................................................................. 12
b. Medical Records Shall Include ...................................................................................... 12
c. Training Records ............................................................................................................ 12
d. Availability Of Records.................................................................................................. 12
e. Transfer Of Records....................................................................................................... 13
f. Evaluation And Review.................................................................................................. 13
2
Appendix A (Job Classification With Potential Exposure List)............................................ 14
Appendix B (Job Classification With No Potential Exposure List)....................................... 15
Appendix C (Sharps Injury Log)............................................................................................... 16
Appendix D (Personal Protective Equipment/Task List)........................................................ 17
Appendix E (Cleaning and Decontamination Schedule)......................................................... 18
Appendix F (Hepatitis B Vaccine Declination)........................................................................ 19
Appendix G (Access to Employee Exposure and Medical Records) .......................................... 20
As required in 29 CFR 1910.1020 Appendix A
....................................................................................................................................................... 20
1Blood Borne Pathogen Exposure Control Plan
V1R4_01.08.2024
1. OBJECTIVE
The objective of the Trilogy MedWaste Bloodborne Pathogen Exposure Control Plan is to
Pathogens Standard, 29 CFR 1910.1030, and to eliminate or minimize employee
occupational exposure to blood other potentially infectious materials.
2. DEFINITIONS
Blood - Human blood, human blood components, and products made from human blood.
Bloodborne Pathogens -Pathogenic microorganisms that are present in human blood and
can cause disease in humans. These pathogens include, but are not limited to,
hepatitis B virus (HBV) and human immunodeficiency virus (HIV).
Contaminated -The presence or the reasonably anticipated presence of blood or other
potentially infectious materials on an item or surface.
Contaminated Laundry -Laundry which has been soiled with blood or other potentially
infectious materials or may contain sharps.
Contaminated Sharps -Any contaminated object that can penetrate the skin including,
but not limited to, needles, scalpels, broken glass, broken capillary tubes, and
exposed ends of dental wires.
Decontamination -The use of physical or chemical means to remove, or destroy
contaminants accumulated on an item to the point where they are no longer
capable of transmitting infectious particles and is rendered safe for handling,
use, or disposal.
Engineering Controls -Includes (e.g., sharps disposal containers, self-sheathing needles,
safer medical devices, such as sharps with engineered sharps injury protections
and needleless systems) that isolate or remove the bloodborne pathogens
hazard from the workplace.
2Blood Borne Pathogen Exposure Control Plan
V1R4_01.08.2024
Exposure Incident -means a specific eye, mouth, other mucous membrane, non-intact
skin, or parenteral contact with blood or other potentially infectious materials
that results from the performance of an employee's duties.
Handwashing Facilities A facility providing an adequate supply of running portable
water, soap, and single-use towels or air-drying machines.
HBV -Hepatitis B Virus.
HIV -Human Immunodeficiency Virus.
Occupational Exposure - Reasonably anticipated skin, eye, mucous membrane, or
parenteral contact with blood or other potentially infectious materials that may
result from the performance of an employee's duties.
Other Potentially Infectious Materials (OPIM) -
The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial
fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in
dental procedures, anybody fluid that is visibly contaminated with blood, and
all body fluids in situations where it is difficult or impossible to differentiate
between body fluids.
Any unfixed tissue or organ (other than intact skin) from a human (living or dead).
HIV containing cell or tissue cultures, organ cultures, and HIV or HBV containing culture
medium or other solutions; and blood, organs, or other tissues from
experimental animals infected with HIV or HBV.
Parenteral -Piercing mucous membranes or the skin barrier through such events as needle
sticks, human bites, cuts, and abrasions.
Personal Protective Equipment -Specialized clothing or equipment worn by an
employee for protection against a hazard. General work clothes (e.g., uniforms,
pants, shirts, or blouses) not intended to function as protection against a hazard
are not considered to be personal protective equipment.
Regulated Medical Waste (RMW) - Liquid or semi-liquid blood or other potentially
infectious materials; contaminated items that would release blood or other
potentially infectious materials in a liquid or semi-liquid state if compressed;
3Blood Borne Pathogen Exposure Control Plan
V1R4_01.08.2024
items that are caked with dried blood or other potentially infectious materials
and are capable of releasing these materials during handling; contaminated
sharps; and pathological and microbiological wastes containing blood or other
potentially infectious materials.
Sharps with engineered sharps injury protections -A non-needle sharp or a needle
device used for withdrawing body fluids, accessing a vein or artery, or
administering medications or other fluids, with a built-in safety feature or
mechanism that effectively reduces the risk of an exposure incident.
Source Individual -Any individual, living or dead, whose blood or other potentially
infectious materials may be a source of occupational exposure to the employee.
Examples include, but are not limited to, hospital and clinic patients; clients in
institutions for the developmentally disabled; trauma victims; clients of drug
and alcohol treatment facilities; residents of hospices and nursing homes;
human remains; and individuals who donate, sell blood or blood components.
Sterilize -The use of a physical or chemical procedure to destroy all microbial life
including highly resistant bacterial endospores.
Universal Precautions - An approach to infection control. According to the concept of
Universal Precautions, all human blood and certain human body fluids are
treated as if known to be infectious for HIV, HBV, and other bloodborne
pathogens.
Work Practice Controls Reduce the likelihood of exposure by altering the manner in
which a task is performed (e.g., prohibiting recapping of needles by a two-
handed technique).
3. BACKGROUND
OSHA requires employers to identify situations and job classifications in which employees
may be exposed to blood or other potentially infectious materials, and to provide protection
to these employees in the form of engineering controls, personal protective equipment,
training, and risk reduction.
4Blood Borne Pathogen Exposure Control Plan
V1R4_01.08.2024
4. ASSIGNMENT OF RESPONSIBILITY
a. Program Administrator
Chad Plata is the Corporate Safety Officer. The Safety Officer shall manage the
Bloodborne Pathogen Exposure Control Plan for Trilogy MedWaste and maintain all
records pertaining to the plan.
The Facility Manager is the Safety Officer at their designated facility. The Safety Officer
will ensure that all affected employees of Trilogy MedWaste are provided adequate
controls and equipment that, when used properly, will minimize, or eliminate risk of
occupational exposure to blood or other potentially infectious materials. These shall be
provided at no cost to the employees.
The Corporate Safety Officer shall review and update this policy, at least annually and
whenever necessary to reflect new or modified tasks and procedures, which affects
occupational exposure and to reflect new or revised employee positions with occupational
exposure.
b. Supervisors/Managers
Supervisors/Managers shall follow and ensure that their employees are trained in and use
proper work practices, universal precautions, the use of personal protective equipment, and
proper cleanup and disposal techniques.
c. Employees
Employees are responsible for adhering to this policy in regard to proper work practices,
universal precautions, personal protective equipment, and cleanup/disposal techniques as
described in this plan. Employees are also responsible for immediately reporting an
exposure incident(s) to the Safety Officer.
d. Contractors
All contract employees that perform tasks that are described in this policy, shall be
responsible for complying with this plan, and shall be provided the training described
herein.
5Blood Borne Pathogen Exposure Control Plan
V1R4_01.08.2024
5. EXPOSURE DETERMINATION
The following job classifications have been determined to have employees who may have
occupational exposure during the course of performing their assigned duties:
Refer to Appendix A - Job Classification With Potential Exposure List
a.Drivers
b.Waste Handler
c.Equipment Technician (Autoclave Operator)
d.Plant Manager
The following job classification(s) have been determined as not having employees who
may have occupational exposure during the course of performing their assigned duties.
Refer to Appendix B - Job Classification With No Potential Exposure List. These lists will
be updated as job classifications or work situations change.
a.Administrative Staff
6. METHODS OF COMPLIANCE
a. Universal Precautions
Universal precautions shall be used at Trilogy MedWaste to prevent contact with blood or
other potentially infectious materials. All blood or other potentially infectious materials
shall be considered infectious, regardless of the perceived status of the source individual.
b. Engineering Controls
Engineering controls will be used to eliminate or minimize exposure. Engineering controls
will be reviewed on a periodic basis to ensure their effectiveness. Examples of engineering
controls include but are not limited to hand dollies and conveyor systems.
c. Work Practice Controls
When engineering controls are not available or feasible, work practice controls will be
used.
6Blood Borne Pathogen Exposure Control Plan
V1R4_01.08.2024
Employees will wash their hands immediately or as soon as feasible after removing
gloves or other personal protective equipment. In the event of contact with blood
or other potentially infectious materials the eyes, nose or mouth, those mucous
membranes will be flushed with water immediately or as soon as feasible.
Eating, drinking, smoking, applying cosmetics (including lip balm) or handling
contact lenses are prohibited in work areas where there is a reasonable likelihood
of occupational exposure.
All containers with untreated medical waste shall be handled in such a manner as
to eliminate spilling or damage to the primary container.
If the primary container leaks or becomes contaminated, employees will put the
container in a secondary container.
Equipment, which may become contaminated with blood or other potentially
infectious materials, shall be disinfected prior to reuse, or processed as medical
waste for disposal.
d. Personal Protective Equipment (PPE)
Personal protective equipment will be used when appropriate to protect employees
from potential occupational exposure incidents. Equipment will be provided to
employees at no cost. Appropriate sizes of personal protective equipment will be
available to employees and when necessary, hypoallergenic gloves or similar
alternative will be provided. The specific equipment for the situation will be
determined by the supervisor in which the potential for occupational exposure
occurs and may include but is not limited to the following: leather palm gloves,
latex gloves, face shield, or apron. At a minimum, gloves will be used whenever
handling medical waste containers. For the purpose of this paragraph, appropriate
shall mean capable of preventing blood or other potentially infectious materials
from passing through or reaching the employee`s skin, mucous membranes, or
clothes under normal conditions of use.
7Blood Borne Pathogen Exposure Control Plan
V1R4_01.08.2024
Employees will be instructed on the proper disposition of their personal protective
equipment. In all cases, disposable gloves will be discarded and replaced as soon
as practical when in disrepair or contaminated. For reusable equipment, cleaning
and disinfection will occur; specific training will be provided to employees. In no
case will employees be allowed to wear their personal protective equipment
outside the work area.
Employees will also be instructed to replace their personal protective equipment
as often as necessary. These replacements will be available at no cost to the
employee. At a minimum, this will occur after each use where the equipment
becomes contaminated and cannot be decontaminated effectively, and when
equipment becomes worn and ineffective.
e. Housekeeping
Housekeeping will be the responsibility of all employees and will be performed
throughout the workday. Spill will be immediately contained and repackaged. The
affected area will then be immediately disinfected.
f. Work uniforms
Uniforms that are contaminated or potentially contaminated with blood or OPIM
shall be handled as little as possible. Such uniforms shall be placed in designated
laundry bags. Trilogy MedWaste will utilize a 3rd party laundry service.
7. HEPATITIS B VACCINES AND POST-EXPOSURE EVALUATION AND
FOLLOW UP
a. Hepatitis B Vaccine
Trilogy MedWaste will make the Hepatitis B vaccine series available to all
employees who have been identified in this plan as having occupational exposure.
The vaccine series will be explained at the employee training session held prior to
8Blood Borne Pathogen Exposure Control Plan
V1R4_01.08.2024
the effective date or within 10 days of initial assignment of the duties that may
result in potential exposure.
Employees identified in the exposure determination will be asked to sign a
Hepatitis B Immunization Form. This form will notify employees that should they
decline to accept the vaccine, yet experience continued occupational exposure,
they can at any time ask for and receive the vaccine series without cost to the
employee.
b. Post-Exposure Evaluation and Follow-up
All employees must report all exposure incidents to the Safety Officer
immediately. The Safety Officer shall investigate and document each exposure
incident. Following a report of an exposure incident, the exposed employee shall
immediately receive a confidential post-exposure evaluation and follow up, to be
provided by an approved Urgent Care Healthcare Provider. The post-exposure
evaluation and follow up shall include the following elements, at a minimum.
Documentation of the route of exposure, and the circumstances under which the
exposure occurred.
Identification and documentation of the source individual, unless it can be
established that identification is infeasible or prohibited by state or local law.
Trilogy MedWaste primarily handles containers that have been pre-packaged by
the generators. Specific source information is typically unavailable.
and after consent is obtained (if consent is required) in order to determine HBV
and HIV infectivity. If not identified, source will be considered potentially
infectious.
When the source individual is already known to be infected with the Hepatitis B
virus (HBV) or human immunodeficiency virus (HIV), testing for the source
9Blood Borne Pathogen Exposure Control Plan
V1R4_01.08.2024
employee, and the employee shall be informed of applicable laws and regulations
concerning disclosure of the identity and infectious status of the source individual.
after consent is obtained.
The exposed employee shall be offered the option of having their blood tested for
HBV and HIV serological status. The blood sample shall be preserved for up to 90
days to allow the employee to decide if their blood should be tested for HBV and
HIV serological status.
Names of employees that contract HIV, Hepatitis, or tuberculosis shall not be
recorded on the OSHA 300 log.
c. Information Provided to the Healthcare Professional
After an exposure incident occurs, Safety Officer shall ensure that the healthcare
well as the healthcare provider providing the post-exposure evaluation, if different,
are provided with the following:
A
emphasis on the confidentially requirements contained therein.
A
exposure incident.
Written documentation of the route of exposure and circumstances under which
the exposure occurred.
R
All medical records relevant to the appropriate treatment of the employee,
including vaccination status.
10Blood Borne Pathogen Exposure Control Plan
V1R4_01.08.2024
d. Healthcare P Written Opinion
The Safety Officer shall obtain and provide the exposed employee a copy of the
of the evaluation.
opinion for HBV vaccination shall be limited
to whether HBV vaccination is indicated for the employees, and if the employee
has received said vaccination.
-exposure follow up shall be
limited to ONLY the following information:
i. A statement that the employee has been informed of the results of the
evaluation
ii. A statement that the employee has been told about any medical conditions
resulting from exposure to blood or other potentially infectious materials
that require further evaluation or treatment.
Other findings or diagnosis resulting from the post-exposure follow up shall
remain confidential and shall not be included in the written report.
8. LABELS AND SIGNS
Biohazard labels are affixed to containers of regulated waste or other potentially infectious
materials. Labels shall also be affixed to any other containers used to store, transport, or
ship medical waste or other potentially infectious materials.
The labels shall be fluorescent orange or orange-red and shall include the universal
biohazard symbol. Red bags or containers with the universal biohazard symbol may be
substituted for labels.
9. TRAINING
The Safety Officer shall ensure that training is provided at the time of initial assignment to
tasks where occupational exposure to blood or other potentially infectious materials may
occur. Training shall be repeated every 12 months, or when there are any changes to tasks
11Blood Borne Pathogen Exposure Control Plan
V1R4_01.08.2024
the education level and language of the affected employees and offered during the normal
work shift. The person conducting the training shall be knowledgeable in the subject
matter. Training shall be interactive and shall include:
a.C
b.Discussion of the epidemiology and symptoms of bloodborne diseases
c.An explanation of the modes of transmission of bloodborne pathogens
d.An explanation of Bloodborne Pathogen Exposure Control
Plan, and how employees can obtain a copy of the plan
e.A description and recognition of tasks that may involve exposure
f.An explanation of the use and limitations of the methods to reduce exposure (such
as engineering controls, work practices, and personal protective equipment)
g.Information about the types, use, location, removal, handling, decontamination, and
disposal of personal protective equipment
h.An explanation of the basis of selection of personal protective equipment
i.Information about the Hepatitis B vaccination (including efficacy, safety, method
of administration, and benefits), as well as an explanation that the vaccination will
be provided at no charge to the employee
j.Instruction on the appropriate actions to take and persons to contact in an
emergency involving blood or other potentially infectious materials
k.An explanation of the procedures to follow if an exposure incident occurs, including
the method of reporting and medical follow up
l.Information on the post-incident evaluation and follow up required for all exposure
incidents
m.An explanation of signs, labels, and color-coding systems.
12Blood Borne Pathogen Exposure Control Plan
V1R4_01.08.2024
10. RECORDKEEPING
a. Medical Records
The Corporate Safety Officer shall maintain medical records as required by 29 CFR
1910.1020. All records shall be kept confidential and shall be retained for at least the
duration of employment plus 30 years.
b. Medical Records Shall Include
Name and social security number of the employee
A
vaccination
Acopy of all results of examinations, medical testing, and follow-up procedures
A copy of the information provided to the healthcare professional, including a
documentation of the routes and circumstances of an exposure.
c. Training Records
The Safety Officer shall maintain training records for three years from the date of
training. Records shall include:
Dates of the training sessions
An outline describing the material presented.
Name(s) of person(s) conducting the training; and
Name(s) of all persons attending the training sessions.
d. Availability Of Records
Whenever an employee (or designated representative) requests access to a record,
Trilogy MedWaste
time, place, and manner in accordance with 29 CFR 1910.1020(e). An employee (or
designated representative) will only be given access to his or her own records.
13Blood Borne Pathogen Exposure Control Plan
V1R4_01.08.2024
e. Transfer Of Records
If Trilogy MedWaste ceases to do business and there is no successor employer to
receive and retain the records for the prescribed period, the Safety Officer shall contact
the Director of the National Institute for Occupational Safety and Health (NIOSH) three
months prior to cessation of business for instruction on final disposition of the records.
f. Evaluation And Review
The Safety Officer shall review this Bloodborne Exposure Control Plan for
effectiveness at least annually and as needed to incorporate changes to the standard or
changes in the workplace.

14Blood Borne Pathogen Exposure Control Plan
V1R4_01.08.2024
Appendix A (Job Classification With Potential Exposure List)
Job Classification Department/Location
Drivers Operations
Waste Handlers Operations
Equipment Technician Operations
Plant Manager Operations
15Blood Borne Pathogen Exposure Control Plan
V1R4_01.08.2024
Appendix B (Job Classification With No Potential Exposure List)
Job Classification Task/Procedure Department/Location
Administrative Staff Record Keeping Administration
16Blood Borne Pathogen Exposure Control Plan
V1R4_01.08.2024
Appendix C (Sharps Injury Log)
Date
Entered
Date &
Time of
Incident
Type &
Brand of
Device
Department or
Work Area
Where Incident
Occurred
Description of Incident
Retain Until ______________________ (five years after end of log year)
17Blood Borne Pathogen Exposure Control Plan
V1R4_01.08.2024
Appendix D (Personal Protective Equipment/Task List)
Job Classification Task/Procedure Type of PPE to be
Used
PPE to be Issued By
Driver Loading/Unloading
Medical Waste
Safety Boots,
Puncture Resistant
Gloves, Safety
Glasses
Manager or
Supervisor
Driver Spill Clean Up Safety Boots,
Puncture Resistant
Gloves, Safety
Glasses
Manager or
Supervisor
Waste Handlers Loading/Unloading
Medical Waste
Safety Boots,
Puncture Resistant
Gloves, Safety
Glasses
Manager or
Supervisor
Waste Handlers Spill Clean Up Safety Boots,
Puncture Resistant
Gloves, Safety
Glasses
Manager or
Supervisor
Equipment
Technician
Loading/Unloading
Medical Waste
Safety Boots,
Puncture Resistant
Gloves, Safety
Glasses
Manager or
Supervisor
Equipment
Technician
Spill Clean Up Safety Boots,
Puncture Resistant
Gloves, Safety
Glasses
Manager or
Supervisor
Plant Manager Loading/Unloading
Medical Waste
Safety Boots,
Puncture Resistant
Gloves, Safety
Glasses
Manager or
Supervisor
Plant Manager Spill Clean Up Safety Boots,
Puncture Resistant
Gloves, Safety
Glasses
Manager or
Supervisor
18Blood Borne Pathogen Exposure Control Plan
V1R4_01.08.2024
Appendix E (Cleaning and Decontamination Schedule)
In the event that medical waste is spilled while handling full containers, the waste will be
immediately contained and repackaged. The affected area will then be immediately
disinfected.
Work areas or equipment that are utilized for the handling of medical waste containers
will be cleaned and disinfected at the end of each workday. An EPA approved disinfected
will be used according to the label and/or SDS instructions.
19Blood Borne Pathogen Exposure Control Plan
V1R4_01.08.2024
Appendix F (Hepatitis B Vaccine Declination)
I understand that, due to my occupational exposure to blood or other potentially infectious
materials, I may be at risk of acquiring the Hepatitis B virus (HBV) infection. I have been given
the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to me. However, I
decline the Hepatitis B vaccination at this time.
I understand that by declining this vaccine, I continue to be at risk of acquiring the serious
disease Hepatitis B.
If in the future, I continue to experience occupational exposure to blood or other potentially
infectious materials and I wish to be vaccinated with the Hepatitis B vaccine, I can receive the
vaccination series at no charge to me.
Employee (print name) _________________________________

Employee (Signature) _____________________________ Date:______________

Safety Officer (print name) _________________________________

Safety Officer (Signature) __________________________ Date:______________
20Blood Borne Pathogen Exposure Control Plan
V1R4_01.08.2024
Appendix G (Access to Employee Exposure and Medical Records)
As required in 29 CFR 1910.1020 Appendix A
I, ______________________________, (full name of worker/patient) hereby authorize
______________________________, (individual or organization holding the medical
records) to release to ______________________________, (individual or organization authorized
to receive the medical information), the following medical information from my personal medical
records:
___________________________________________________________________
___________________________________________________________________
(Describe generally the information desired to be released).
I give my permission for this medical information to be used for the following purpose:
___________________________________________________________________
___________________________________________________________________
but I do not give permission for any other use or re-disclosure of this information.
(Note: Several extra lines are provided below so that you can place additional restrictions on this
authorization letter if you want to. You may, however, leave these lines blank. On the other hand,
you may want to (1) specify a particular expiration date for this letter (if less than one year); (2)
describe medical information to be created in the future that you intend to be covered by this
authorization letter; or (3) describe portions of the medical information in your records which you
do not intend to be released as a result of this letter.)
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Full name of Employee or Legal Representative: ______________________________
Signature of Employee or Legal Representative: ______________________________
Date of Signature: ______________________________
#280 – Operations Plan
V1R1-20240724 19
Attachment 2

Regulated Medical Waste (RMW)
Acceptance Policy

Contents
1. PURPOSE ...................................................................................................................................................................1
2. OBJECTIVE .............................................................................................................................................................1
3. REGULATED MEDICAL WASTE .............................................................................................................1
4. WASTE SEGREGATION AND PACKAGING.....................................................................................2
5. MANAGEMENT OF NON-CONFORMING WASTE ......................................................................2
6. ACCEPTED RMW................................................................................................................................................3
a. Sharps........................................................................................................................................................................3
b. RMW or Clinical Waste or Biomedical Waste.............................................................................................3
7. ACCEPTED RMW - MUST BE IDENTIFIED, SEGREGATED FOR INCINERATION .3
a. Trace Chemotherapy Contaminated Waste .................................................................................................3
b. Pathological Waste................................................................................................................................................3
c. Non-RCRA Pharmaceuticals.............................................................................................................................3
d. California Only.......................................................................................................................................................3
8. NOT ACCEPTED - RMW NOT ACCEPTED BY TRILOGY MEDWASTE .......................3
a. Untreated Category A Infectious Substances............................................................................3
b. Complete Human Remains (including heads, full torsos, and fetuses)......................................3
c. Bulk Chemotherapy Waste.......................................................................................................3
d. Mercury-Containing Dental Waste...........................................................................................4
e. Mercury Containing Material or Devices .................................................................................4
f. RCRA Hazardous Pharmaceutical Waste and all DEA Federal and state-controlled
substances*......................................................................................................................................4
g. Chemicals.................................................................................................................................4
h. Compressed Gas Cylinders, Canisters, Inhalers and Aerosol Cans ..........................................4
i. Hazardous or Universal Waste .................................................................................................4
j. Radioactive Waste .................................................................................................................................................4
1 Regulated Medical Waste Acceptance
V2R1_113022
1. PURPOSE
The purpose of this policy is to summarize the minimum requirements for preparing your
RMW for collection, transportation, and treatment. Additional facility or state-specific waste
acceptance policies may apply based on permit specifications.
2. OBJECTIVE
Trilogy MedWaste policy requires compliance with all applicable regulations regarding the
collection, transportation, and treatment of RMW. Federal Department of Transportation
(DOT) regulations require the generator of RMW to certify that the packaging and
documentation of transported RMW complies with DOT regulations regarding waste
classification, packaging, labeling,and shipping documentation. To ensure that neither TMW
nor the generator of RMW violates applicable regulations, it is imperative that all parties
understand the rules regarding proper identification, classification, segregation, and
packaging of RMW.
Please contact your local TMW representative for further information or email
[e-mail].
3. REGULATED MEDICAL WASTE
TMW accepts medical waste generated in a broad range of medical, diagnostic, therapeutic
infectious or RMW as defined under federal, state, or local laws, rules, regulations, and
guidelines. Except as defined by specific state regulations, this excludes RCRA hazardous
waste pharmaceuticals, all DEA scheduled drugs including *controlled substances, bulk
chemotherapy, waste containing mercury or other heavy metals, batteries of any type,
cauterizers, non-infectious dental waste, chemicals such as solvents, reagents, corrosives, or
ignitable materials classified as hazardous waste under Federal and/or state-specific EPA
Regulations. In addition, TMW cannot accept bulk liquids, radioactive materials, or complete
human remains (including heads, full torsos, and fetuses). TMW cannot accept these
excluded materials packaged as RMW. All lab wastes or materials which contain or have the
potential to contain infectious substances arising from those agents listed under 42 CFR Part
2 Regulated Medical Waste Acceptance
V2R1_113022
73 (HHS), 7 CFR Part 331 (USDA-Plant Protection and Quarantine), and 9 CFR Part 121
(USDA-Veterinary Services) are strictly prohibited from medical waste by federal law and
must be pretreated prior to disposal. Separate protocol and packaging requirements may
apply for the disposal of non-hazardous pharmaceuticals. Hazardous waste transportation
services may be offered in certain geographical locations, under separate contract. Please
contact your local TMW representative for details and packaging specification.
4. WASTE SEGREGATION AND PACKAGING
The generator is solely responsible for properly segregating, packaging, and labeling of
RMW. Proper segregation and packaging reduce the potential for accidental release of the
contents and exposure to employees and the general public. DOT regulations (49 CFR
173.197) require that all packages of RMW be prepared for transport in containers that meet
all of the following requirements: rigid, leak resistant, impervious to moisture, of sufficient
strength to prevent tearing or bursting under normal conditions of use and handling, sealed
to prevent leakage during transport and puncture resistant for sharps. All RMW must be
accompanied by a properly completed shipping document (See 49 CFR 172.202).
5. MANAGEMENT OF NON-CONFORMING WASTE
As required by regulation and company policy, TMW employees may refuse containers that
are non-conforming because of their contents or are improperly packaged, leaking, damaged
or likely to create a risk of exposure to employees or the general public. Any waste found to
be non-conforming to this Waste Acceptance Policy identified in route to, or at a TMW
facility, may be returned to the generator for proper packaging and disposal, or may be
rerouted for appropriate destruction; this may include improperly marked RMW which
should have been identified for incineration (i.e., pathological, chemotherapy or non-
hazardous pharmaceuticals). Proper segregation and packaging are essential to ensure
compliant and safe handling, collection, transportation, and treatment of RMW.

3 Regulated Medical Waste Acceptance
V2R1_113022
6. ACCEPTED RMW
a. Sharps -Means any object contaminated with a pathogen or that may become
contaminated with a pathogen through handling or during transportation and also
capable of cutting or penetrating skin or a packaging material. Sharps includes needles,
syringes, scalpels, broken glass, culture slides, culture dishes, broken capillary tubes,
broken rigid plastic and exposed ends of dental wires.
b. RMW or Clinical Waste or Biomedical Waste -Means a waste or reusable material
derived from the medical treatment of an animal or human, which includes diagnosis
and immunization, or from biomedical research, which includes the production and
testing of biological products.
7. ACCEPTED RMW - MUST BE IDENTIFIED, SEGREGATED FOR
INCINERATION
a. Trace Chemotherapy Contaminated Waste:RCRA Empty drug vials, syringes and
needles, spill kits, IV tubing and bags, contaminated gloves and gowns and related
materials as defined in applicable laws, rules, regulations, or guidelines.
b. Pathological Waste:Human or animal body parts, organs, tissues, and surgical
specimens (decanted of formaldehyde, formalin or other preservatives as required per
hazardous waste rules).
c. Non-RCRA Pharmaceuticals:Must be characterized and certified as non-RCRA
hazardous material by the generator. Excludes all DEA scheduled drugs, including
controlled substances*.
d. California Only - Solidified Suction Canisters:Suction canisters that have been
injected with solidifier materials to control liquids or suction canisters made of high
heat resistant plastics such as polysulfone.
8. NOT ACCEPTED - RMW NOT ACCEPTED BY TRILOGY MEDWASTE
a.Untreated Category A Infectious Substances
b.Complete Human Remains (including heads, full torsos, and fetuses)
c.Bulk Chemotherapy Waste
4 Regulated Medical Waste Acceptance
V2R1_113022
d.Mercury-Containing Dental Waste: Non-contact and contact amalgam and products,
chairside traps, amalgam sludge or vacuum pump filters, extracted teeth with mercury
fillings and empty amalgam capsules
e.Mercury Containing Material or Devices: Any mercury thermometers,
sphygmomanometers, lab, or medical devices
f.RCRA Hazardous Pharmaceutical Waste and all DEA Federal and state-controlled
substances*
g.Chemicals: Formaldehyde, formalin, acids, alcohol, waste oil, solvents, reagents,
fixer developer, fluorescein
h.Compressed Gas Cylinders, Canisters, Inhalers and Aerosol Cans
i.Hazardous or Universal Waste: Any other waste determined by Federal or State EPA
regulations including but not limited to batteries, bulbs, heavy metals, etc.
j.Radioactive Waste: Any container with a radioactivity level that exceeds regulatory
or permitted limits; lead-containing materials
#280 – Operations Plan
V1R1-20240724 20
Attachment 3
Radiation Screening Protocol
TMW
V1R3-20230330
Table of Contents
1) INTRODUCTION ............................................................................................................. 1
2) GENERAL REQUIREMENTS .................................................................................... 1
3) RADIATION MONITOR ............................................................................................... 2
4) CALIBRATION AND INSPECTION PROCEDURES ....................................... 2
5) WASTE SCREENING .................................................................................................... 2
6) ALARM RESPONSE PROCEDURES ...................................................................... 3
a) PROCEDURE #1............................................................................................................... 3
Exposure rate is Less than 1000 uR/hr (1mR/hr)........................................................................ 3
b) PROCEDURE #2............................................................................................................... 4
Exposure rate is Greater than 1000 uR/hr (1mR/hr) and Less than 2000 uR/hr (2mR/hr):......... 4
c) PROCEDURE #3............................................................................................................... 4
Exposure rate exceeds 2000 uR/hr (2mR/hr) at any time............................................................ 4
7) STATE REGULATORY AGENCY NOTIFICATION ........................................ 4
Attachment 1: Radiation Tracking Document (Less than 1000uR/hr)
Attachment 2: Radiation Tracking Document (Greater than 1000 uR/hr)
Attachment 3: Radiation Decay Chart
V 1 R 3 _ 2 0 2 3 0 3 3 0 P a g e | 1
Radiation Screening Protocol
1) INTRODUCTION
It is Trilogy MedWaste’s Policy to prohibit the treatment or disposal of medical waste that
also contains regulated sources of radiation. Trilogy MedWaste will reject all radioactive
waste containers.
All containers will be subject to our Waste Screening Procedure as detailed in this policy.
This document describes the procedures designed to enforce this policy.
2) GENERAL REQUIREMENTS
a) Ensure that written detection and response procedures are posted where they can be
seen and followed by the personnel performing the waste monitoring. The alarm
procedures should be coordinated in advance with facility personnel and appropriate
State or Federal agencies.
b) Ensure that facility personnel required to conduct waste screening and response
procedures are trained prior to assignment on the appropriate procedure to be followed
in the event the alarm is activated.
c) Ensure that at least one individual per shift is trained in and responsible for the
implementation of response procedures in the event an alarm is activated.
d) Ensure that the alarm setpoint is no higher than three times ambient background.
e) Ensure that an area away from normal work areas has been designated for the isolation
of medical waste that has caused the radiation detector to alarm.
V 1 R 3 _ 2 0 2 3 0 3 3 0 P a g e | 2
Radiation Screening Protocol
3) RADIATION MONITOR
A Ludlum Model number 375 radiation monitor, or approved equal monitor, will be
permanently mounted next to the container scanning station. The monitor will be set at three
times the background level. The monitor will be equipped with an alarm to signal the shop
workers that a container exceeds the acceptable limit.
4) CALIBRATION AND INSPECTION PROCEDURES
a) The radiation screening unit shall be calibrated annually. Calibration documents shall
be maintained for three (3) years.
b) The radiation screening unit shall be inspected daily to insure that the unit is
functioning properly. This daily inspection shall ensure that the unit is turned on prior
to use. In addition, verify alarm is working properly by using a check source (CS137).
Place check source on the detector and verify audible alarm.
c) If the radiation screen unit fails the inspection, immediately report to supervisor.
5) WASTE SCREENING
a) Pass each medical waste container slowly through the radiation detection area. If the
alarm does not sound, the container can be assumed to be free of radioactive material.
b) If the alarm sounds, reset the monitor alarm and pass the container through the
detection area a second time. If the alarm does not sound on the second pass, the alarm
can be assumed to have been false and the container can be considered to be free of
radioactive materials.
c) If the alarm sounds on the second pass, this reading will be recorded as the initial
reading. This value will determine the next steps and documents to be utilized.
V 1 R 3 _ 2 0 2 3 0 3 3 0 P a g e | 3
Radiation Screening Protocol
6) ALARM RESPONSE PROCEDURES
a) PROCEDURE #1
Exposure rate is Less than 1000 uR/hr (1mR/hr)
i) Place container in isolation area.
ii) Compete the “Radiation Tracking Document Less than 1000 uR/hr”. Refer to
Attachment 1.
iii) Measure the exposure rate in uR/hr or mR/hr over the entire package to find the
highest reading. Mark the location of the highest reading directly on the package.
Record the highest exposure rate observed under “Recoding A” as the Initial
Reading of the Radiation Tracking Document. Also, record the date and time this
initial reading was taken, as well as the Generator Name and Account Number.
iv) 24 to 48 hours after the initial reading; re-measure the exposure rate at exactly the
marked location on the package. Record this reading under “Recoding B” Also,
record the elapsed time in hours from initial reading.
v) Using the Radiation Decay Chart, put your finger on the initial measurement value
in the left-most column labeled “Initial Reading (uR/hr)”. Move your finger to the
right along this row until you get to the column which represents the elapsed time.
Record the number, which occurs at the intersection of this elapsed time column
and the initial reading row in “Recoding C”.
vi) If the number recorded in “Recoding C”. is equal to or greater than the reading
recorded in “Recoding B”, the package may be placed back in the waste stream
and processed once the radiation level is less than the acceptable radiation limits
(no alarm). The half-life is less than 10 days.
vii)If the number recorded in Recoding Cis less than the reading recorded in Recoding
B, place container back in isolation and notify your supervisor.
viii)The generator must be contacted, and the generator must make arrangements for
the rejected container to be removed from our facility.
V 1 R 3 _ 2 0 2 3 0 3 3 0 P a g e | 4
Radiation Screening Protocol
b) PROCEDURE #2
Exposure rate is Greater than 1000 uR/hr (1mR/hr) and Less than 2000 uR/hr
(2mR/hr):
i) Place container in isolation area.
ii) Complete “Radiation Tracking Document – Greater than 1000 uR/hr”. Refer to
Attachment #2.
iii) The generator must be contacted and the generator must make arrangements for
the rejected container to be removed from our facility.
c) PROCEDURE #3
Exposure rate exceeds 2000 uR/hr (2mR/hr) at any time.
i) Immediately isolate the container,
ii) Clear the area and notify supervisor and Corporate Compliance.
iii) Supervisor will immediately notify the generator and the appropriate state
regulatory agency.
iv) The supervisor will need to complete the “Radiation Tracking Document –Greater
than 1000 uR/hr”. Refer to Attachment #2.
7) STATE REGULATORY AGENCY NOTIFICATION
a) Only containers exceeding 2000 uR/hr (2mR/hr) will require notification to the State
Agency.
b) When contacting the State Regulatory Agency, have the completed “Radiation
Tracking Document – Greater than 1000 uR/hr”. Refer to Attachment #2.
c) Follow any instructions given by the State Regulatory Agency.
d)Under no circumstances will Trilogy MedWaste personnel transport regulated
radioactive material over public highways. The responsibility for proper
transportation of regulated radioactive material rests with the generator
(licensee).
#280 – Operations Plan
V1R1-20240724 21
Attachment 4
Truck Unloading
Park and secure the truck
Upon returning to warehouse, check in with plant supervisor for
proper location to unload tubs.
Unsecure tubs.
Use hand truck and dock plate
Move tubs into warehouse and place into correct location for
weighing or segregation.
Loading Trucks
Obtain Tracking Documents from supervisor.
Determine proper tub count for route.
Supervisor or trainer will provide information on tub count.
Gather correct size and color of tubs.
Use dolly to wheel to back of truck
Load on truck and secure from movement.
Load any miscellaneous supplies.
Close and lock back door of truck.
Grab paperwork, handheld, and printer and depart for route
#280 – Operations Plan
V1R1-20240724 22
Attachment 5
Exhibit C
Gloves
Disinfectant (Bleachor approved EPAdisinfectant)
Sprayer
EAP – TMW
Revision: DTV
#280 – Operations Plan
V1R1-20240724 23
Attachment 6
WASHING CONTAINERS
STANDARD OPERATING PROCEDURES
1. Remove waste from containers
2. Spray containers with Virex ll 256 solution and let sit for 5 to 10 minutes
3. Rinse containers
4. Stand containers up with open end facing down to let them drain
5. Flip containers over so open end is up and spray with odor remover
6. Inspect for cleanliness and odor
7. Stack containers
8. Use the hand truck to move the containers to the area designated for clean
containers
PPE REQUIREMENTS
Rubber Gloves
Safety toed work boots
Uniform
Safety Goggles
#280 – Operations Plan
V1R1-20240724 24
Attachment 7
EAP –TMW7 _V1R _0 22
Emergency Action Plan
(EAP)
Medical Waste
TMW - 7

TABLE OF CONTENTS
Emergency Response Plan and Contingency Plan ..................................................... 3
Exhibit A: Evacuation Map ...................................................................................... 8
Exhibit B: Emergency Contact Information ............................................................. 9
Exhibit C: Spill Response ..................................................................................... 1
Certificate of Receipt .............................................................................................. 1
EAP –TMW7 _V1R _0 22
Page 3
EMERGENCYRESPONSEPLANAND
CONTINGENCY PLAN
Introduction
Thisplancontains procedures for TrilogyMedWaste personnel to followin the event of an
emergency.
This planhas been prepared for the following purposes:
To be a guide for action during emergency/disaster situations.
To prevent or minimize dangers to human health and the environment resulting from the
accidental release of medical waste.
To assist in training company personnel in the proper performanceoftheir duties.
To familiarize local emergency response personnel with the material handled, company
operations and internal response procedures.
This plan shall be implemented by qualified company personnel immediately upon the possible or
actual release of medical waste into the environment. It is the Emergency Coordinator’s
responsibility to determine the nature of any accident or emergency. Some accidents are common.
These do not require the implementation of the Emergency Action Plan. Only those designated by
the Emergency Coordinator will require him/her to invoke this action plan.
Emergency Coordinator
The Emergency Coordinator has primary responsibility for managing all emergency response
activity and will be the first one to be notified in the event of an emergency or accident. The
Emergency Coordinator is familiarwith the Emergency Action Plan and all Company operations,
the location and nature of the waste handled, the location of records, vehicles and layout of both
Company and generator facilities.
Summaryof Emergency Coordinator’s Responsibilities:
• Immediately determine if the accident or emergency is one that requires the
implementation of the EmergencyActionPlan. If in fact he/she determines that the plan
needs to be implemented then he/she will immediately identify and assess the source,
amount and extent of material released and of any other danger present.
• Notify all personnel in the area.
• Notifystateandlocal emergency response agenciesiftheirassistance is needed and
determine whether evacuation is necessary.
• Arrangefor emergency assistancefor injured personnel.
• Notify State Environmental Agency.
• Assess the possible dangers to human health or to the environment that may result from the
incident.
EAP –TMW7 _V1R _0 22
Page 4
EMERGENCY RESPONSE PLAN AND
CONTINGENCY PLAN
• Take measures to prevent the spread of fire, release of waste or any other present danger.
• Managecleanupefforts, including proper disposal of recoveredwaste or contaminated
material.
• Restore emergency equipment for future use.
• Provide and maintain emergency equipment in proper locations and in proper condition for
immediate use.
Off Site Generator Contingency
Trilogy MedWaste utilizes a fleet of company owned and leased power units and transport
vehicles (i.e.: 16-foot box trucks, 24-foot box trucks, 28-foot refrigerated trailers).
Trilogy MedWaste is capable of processing up to 48 tons (96,000 pounds) of medical waste per
day and is authorized to store the medical waste up to 30 calendar days.
As a contingency for generators, Trilogy MedWaste maintains an inventory of reusable
(tubs and 96 gal totes) and single use (cardboard boxes) containers that would be
equivalent to 7 days (1 week) of un-interrupted services to generators that are essential to
continual operations during a declared major natural disaster weather event.
Trilogy MedWaste emergency coordinator or alternate will communicate with the designated
representative of the essential generator’s facility for the removal of medical waste.
Trilogy MedWaste has multiple permitted transport facilities that will be utilized as
additional resources and serve as the alternate biomedical waste transporter.
Natural Disaster Policy (Hurricane Preparedness)
It is Trilogy MedWaste’s intent to handle medical waste pick-ups as promptly and efficiently as
possible in the event of the occurrence of a natural disaster. Every effort will be made to
complete scheduled pick-ups in the affected areas after receiving permission from all state and
federal agencies to do so. Trilogy MedWaste will also do everything practical in order to provide
our customers with adequate supplies, including extra boxes, containers and liners, upon their
request, subsequent to the issuance of a hurricane warning by the National Hurricane Center for
their region.
The National Weather Service announces four levels ofwindstorm alerts: tropical storm watch,
tropical storm warning, hurricane watch, and hurricane warning, which are defined as follows:
•Tropical storm watch – Tropical storm conditions with sustained winds from 39-74
mph are possible in your area within the next 36 hours.
•Tropical storm warning – Tropical storm conditions are expected in your area within
the next 24 hours.
EAP –TMW7 _V1R _0 22
Page 5
EMERGENCY RESPONSE PLAN AND
CONTIGENCY PLAN
•Hurricane watch – Hurricane conditions with sustained winds of 74 mph or greater
are possible in your area within the next 36 hours. This watch should trigger your
organization’s disaster plan, and protective measures should be initiated.
•Hurricane warning – Hurricane conditions are expected in your area within 24 hours.
Once this warning has been issued, you should be in the process of completing
protective actions.
Safety of our employees will always take precedence.
All mandatory evacuations issued by local city, county, and/or state officials will be strictly
adhered to.
Emergency Procedures
Evacuation Procedure
Notify site personnel of the evacuation via oral instructions.
SHELTER IN PLACE: In the event of a shelter in place, all employees would seek shelter
in the restrooms. The emergency response coordinator(s) would account for all employees
at the shelter in place location. The emergency response coordinator(s) would monitor the
change in the weather and notify all employees when it’s safe to return to work.
RALLY POINT: Personnel and visitors should be directed to take the safest route out of the
site and reassemble at the “rally point” designated for this site:
If outside emergency support is required, call the emergency number 911, and report
the emergency. Inform the operator that there is an emergency and:
Caller’s name and location.
Type of emergency.
Emergency aid required.
Stay on the line and answer all questions until told to hang up.
Advise the Emergency Coordinator or Alternate Emergency Coordinator of the situation and
notifications made.
EAP –TMW7 _V1R _0 22
Page 6
EMERGENCY RESPONSE PLAN AND
CONTIGENCY PLAN
TheEmergency Coordinator or AlternateEmergency Coordinator will be responsible for:
Coordinating evacuation of the site including notification of adjacent property
owners/tenants as required.
Coordinating with incoming emergency response personnel.
Conducting a head count at the designated assembly area or “rallypoint”.
Notifying other drivers to avoid the site.
Notifying the Regional Manager of the emergency.
Determining when the “all clear” signal can be given to return to the site.
Fire Procedure
Orally warn personnel on-siteandcall the emergency number 911 toreport the fire. Inform the
operator that there is a fire emergency and:
Caller’sname and location.
Location of fire.
If known, materials involved.
Whether medical aid is required.
Stay on the lineand answer all questions until toldto hang up.
If the fire is small (less than 1 cubic yard), can be approached safely with an escape route, and
available personnel are trained in the use of the appropriate fire extinguisher, an attempt can be
made to put the fire out.
If unable to extinguish the fire, evacuate the siteand proceedto the designated re-assembly
area or “rally point”.
Advise a supervisor or the Emergency Coordinator of the situation and notifications made.
The Emergency Coordinator or Alternate Emergency Coordinator in charge will be responsible
for:
Coordinating evacuation of the site if required.
Coordinating with incoming emergency response personnel.
Conducting a head count at the designated assembly point.
Notifying drivers to avoid the yard.
Notifying the Regional Manager of the emergency.
Medical Emergency Procedure
Get a helper. If you are qualified, begin first aid (e.g., stop bleeding, begin CPR, etc.). Do not
move victim unless necessary to prevent further injury.
Call emergency number 911. Inform the operator that there is a medical emergency and:
Caller’s name and location.
Location of victim.
Nature and extent of injury/illness.
EAP –TMW7 _V1R _0 22
Page 7
EMERGENCY RESPONSE PLAN AND
CONTIGENCY PLAN
Stay on the line and answer all questions until you are told to hang up.
Advise the Emergency Coordinator or Alternate Emergency Coordinator of the situation and
notifications made.
Continue necessaryfirst aid and keep victim warm and quiet until help arrives.
TheEmergency Coordinator or AlternateEmergency Coordinator incharge will be responsible for:
Coordinating with incoming emergency response personnel.
Notifying the Regional Manager of the emergency.
Spill/Release/Emission Response Procedure
Alert personnel in the immediate area. If required, secure facility and evacuateto upwind site
or designated reassembly area.
Isolate affected area from incoming traffic and personnel.
If safeandtrainedin use of required protective equipment, contain spill or block off drains
downstream.
If unable tocontain or clean-up spill safely,call emergency number 911. Inform operator that
there is a spill emergency and:
Caller’s name and location.
Location of spill.
If known, materials and volumes involved.
Whether medical aid is required.
Whether fire hazard exists.
Stay on the line and answer all questions until you are told to hang up.
Advise the Emergency Coordinator or Alternate Emergency Coordinator of the situation and
notifications made.
TheEmergency Coordinator or Alternate Emergency Coordinator in charge will be responsible
for:
Coordinating with incoming emergency response personnel.
Notifying the Regional Manager of the emergency.
Additional Environmental Reporting may be necessary.
EAP –TMW7 _V1R _0 22
Exhibit A
EXHIBIT A:
EVACUATION MAP
EAP –TMW7 _V1R _0 22
Exhibit B
EXHIBIT B:
EMERGENCY CONTACT INFORMATION
Trilogy MedWaste Key Personnel
EmergencyCoordinator
Cell ()
Corporate Environmental, Safety and Health
Chad Plata
Director Compliance, ES&H
Cell [phone]
Emergency Telephone Numbers
Alternate Emergency Coordinator
District Manager
Cell(
EMERGENCY RESPONSE AGENCIES
Ambulance
Fire Department
Police Department
Highway Patrol
MEDICAL CLINIC & HOSPITAL:
Urgent Care Clinic
Hospital
911
911
911
911
()
()
EAP –TMW7 _V1R _0 22
Exhibit C
Gloves
Disinfectant (Bleachor approved EPAdisinfectant)
Sprayer
EAP –TMW7 _V1R _0 22
Certificate of Receipt
CERTIFICATE OF RECEIPT
EmergencyAction
Plan
By my signature below I acknowledge that I have received the policy indicated. I had the opportunity to ask
questions and receive answers on the contents of this policy. I understand I can contact my supervisor,
HR or Corporate Compliance should I have additional questions or require more information to properly
apply the principles presented in this policy.
Date
Employee Name (printed)
EmployeeSignature
EAP –TMW7 _V1R _0 22
#280 – Operations Plan
V1R1-20240724 25
Attachment 8
Autoclave Operation
In accordance with Utah Department of Environmental Quality R315-316-5 (4a)
Time-30 minutes
Temperature-Must reach temperature of at least 250 degrees Fahrenheit
Pressure-22 PSI
Type of waste- Regulated medical waste
Type of container-Turbo FS 1200 Autoclave
Closures of container- See opening and closing the door below
Pattern of loading-see loading and unloading below
Water content-The autoclave uses steam which condenses into approximately 10
gallons of water which is released when the autoclave door is opened. Caution the
water is hot.
Maximum load quantity-6 autoclave carts
Turning The Autoclave On:
1. Turn air compressor switch to on.
2. Flip switch on feed water tank to the right “A”
3. Turn on the boiler
Wait for the boiler to warm up, check temperature gauge on the stack
(needs to be 250 Degrees F) and the pressure gauge needs to be at 5 kpa
X 1000)
4. When boiler is ready, partially open valve 2 (red) on the west side of the
autoclave near the floor
5. Partially open valve 1 (Green) also on the west side of the autoclave
When the flowing water is replaced by steam continue to open up the
valves until they are completely open.
6. Turn power switch on the clave to on
Make sure pressure release valve is closed
7. Remove old chart recorder and file, replace with dated new chart
8. Open valve 3 (green by the back man door)
9. Press the Start Cycle button (close valve 3 after 10 minutes)
10.When the cycle is done open valve 3 (green, by the back door) for 10 minutes
then close
#280 – Operations Plan
V1R1-20240724 26
Opening The Autoclave Door:
1. Check area is clear
2. Check the pressure gauges located by the control panel of the autoclave to verify
pressure has reached 0 PSI.
3. MAKE SURE THE PRESSURE RELIEF VALVE IS OPEN AND PRESSURE
RELIEVED.
4. Twist button to open the door
Unloading The Autoclave:
1. Open the door
2. Squeegee any water that leaks from the clave.
3. Put the ramps into place
4. Wear appropriate PPE (Required: safety work boots, Work uniform, safety
glasses, face shield, nitrile gloves, heat resistant gloves, needle resistant arm
guards. Optional: Respirator)
5. Verify that the temperature has dropped to a maximum of 160 degrees
Fahrenheit.
6. Pull the carts down the ramp one at a time until all of the carts are removed
Loading The Autoclave:
1. Open the door
2. Put the ramps into place
3. Wear the appropriate PPE (Required: safety work boots, Work uniform, safety
glasses, face shield, nitrile gloves, needle resistant gloves, needle resistant arm
guards. Optional: Respirator)
4. Push the loaded carts into the autoclave one at a time until clave is fully loaded.
5. Close the door
#280 – Operations Plan
V1R1-20240724 27
Closing The Autoclave Door:
1. Ensure that the ramps and all debris are clear so the door can close
2. Push the door closed and hold
3. Twist button to close the door
NOTE: If you are running multiple loads begin at step 8 of turning the autoclave on and
repeat procedures.
Turning The Autoclave Off:
1. Turn power switch to the off position
2. Turn off Boiler, lock boiler house
3. Close valves 1& 2
4. Turn off the Compressor
Certification of Training
I certify that I have been trained on and understand the written operating procedures of
the autoclave as outlined in the document “Autoclave Operation”. This training included
the following topics in accordance with Utah Department of Environmental Quality
R315-316-5 (4a):
Time
Temperature
Pressure
Type of Waste
Type of container
Closure of container
Pattern of loading
Water content
Maximum load quantity
_______________________
Printed name
_______________________
Signature
_______________________
Date
Attachment 9
Boiler Operation
Turning on
1. Unlock boiler house
2. Check site glass on boiler for water, do not proceed until you can see water in
the site glass
3. Turn on feed pump 1 or 2 (alternate days)
4. Wait for secondary water light on boiler to turn on
5. Turn on switch for boiler
6. Push the reset to activate
Turning off
1. Turn off boiler
2. Turn off feed pump
3. Blow boiler down for 10-15 seconds per valve
4. Lock boiler house
Attachment 10
Trilogy MedWaste West 780
Daily Housekeeping Inspection Checklist
Inspection Date: Inspector:
Front Office Completed
1 Desks neat clean and orderly
2 Garbage’s emptied if needed
3 Files and Binders put away and locked when appropriate
4 Cleaners, tools, and inventory put where it belongs
Break room Completed
1 Visitor Log, PPE, and Cabinet orderly
2 Garbage’s Emptied
3 Tables cleaned off, and wiped down
4 All hangers, clothes, and boots put away
Bathrooms Completed
1 Sink and Mirror cleaned
2 Toilet Cleaned
3 Garbage Emptied
4 Paper Towels filled
5 Soap dispenser filled
Shop Completed
1 Make sure all unprocessed waste has a lid and is stacked orderly
2 Inspect floor for sharps, spills, and general cleanliness
3 Back table is cleaned and orderly
4 Compactor is pushed in
5 Return PPE, Tools, Cleaning Supplies, and everything back in there place
Outside Completed
1 Walk around boiler and compactor to make sure no sharps or waste on the ground
2 Make sure boiler is turned off and boiler house is closed
3 Clean up the front of the building
Any items noticed during the daily walkthrough and housekeeping inspection that need attention:
Signed: