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Medical Waste Disposal | Laboratory Waste Management | Biohazardous Waste Disposal
Clean Scene Services offers Biohazardous waste disposal of all types. We are permitted to transport medical waste and hazardous waste within the state of California.
We pick-up infectious medical waste from hospitals, clinics, colleges, universities, doctor's offices, dentist's offices, pathology laboratories, histology labs, hotels, motels, veterinary clinics, property managers and owners, realtors, movie studios, and many others, both public and private.
Red bag waste, Sharps waste, Laboratory Specimens, Pathology Specimens, Formalin and Formaldehyde, Reagents, Paraffin Blocks and Micro-Slides, Petri Dishes, Expired Pharmaceuticals and ALL types of medical waste.
You can also have your formalin recycled and rebuffed. Formalin recycling can help your facility in your efforts to "GO GREEN". Call us NOW to see how you can get started with our formalin recycling program.
Clean Scene Services has been serving California since 1996. Not all medical waste disposal companies are the same. We are a licensed Medical Waste and Hazardous Waste Hauler. EPA/DOT#3739. We are also licensed as a Trauma Scene Waste Management Practitioner. California Department of Public Health # TSW-003.
Our services are provided on an at need basis. No contacts. No stop charges. No medical waste tracking document fees. No fuel surcharges. Many of our clients do not need a weekly or monthly pick-up. Clients with a one time need and/or calling semi-annually.are the clients that save the most with our services.
Usually your infectious waste can be removed within 24 hours of calling, at no additional charge. There is however, an additional charge on emergency service pick-ups. Emergency service calls are usually handled within 2 hours of calling, depending upon traffic and weather conditions.
Emergency biohazard spill response available 24 hours. Clean-up and disinfection of any biohazard. After hours medical waste pick-ups also available. Let us help you and your business to stay in compliance with the California Medical Waste Management Act.
CALL US NOW TO SEE HOW WE CAN HELP YOU WITH YOUR BIOHAZARDOUS WASTE DISPOSAL NEEDS.
Toll Free 1-877-246-4292 1-877-BIO-HAZARD
Medical Waste Management Act
California Health and Safety Code
Medical Waste Management Act
California Health and Safety Code
Sections 117600 – 118360 January 2007 2
Table of Contents
CHAPTER 1 - GENERAL PROVISIONS................................................................................................6
117600 - CITATION OF PART.....................................................................................................................6
117605 - PREEMPT.................................................................................................................................6
117610 - REGULATIONS..........................................................................................................................6
117615 - LOCAL ORDINANCE...................................................................................................................6
117620 - INITIATE PROGRAM....................................................................................................................6
CHAPTER 2 - DEFINITIONS....................................................................................................................6
117625 - DEFINITIONS.............................................................................................................................6
117630 - BIOHAZARD BAG........................................................................................................................6
117635 - BIOHAZARDOUS WASTE............................................................................................................6
117640 - COMMON STORAGE FACILITY...................................................................................................8
117645 - CONTAINER...............................................................................................................................8
117650 - ENFORCEMENT AGENCY...........................................................................................................8
117655 - ENFORCEMENT OFFICER..........................................................................................................8
117657 - FUND........................................................................................................................................8
117660 - HAZARDOUS WASTE HAULER...................................................................................................8
117662 - HEALTH CARE PROFESSIONAL.................................................................................................9
117665 - HIGHLY COMMUNICABLE DISEASES..........................................................................................9
117670 - HOUSEHOLD WASTE.................................................................................................................9
117671 – HOME-GENERATED SHARPS WASTE.......................................................................................9
117672 - INDUSTRIAL HYGIENIST.............................................................................................................9
117675 - INFECTIOUS AGENT...................................................................................................................9
117680 - LARGE QUANTITY GENERATOR................................................................................................9
117685 - LOCAL AGENCY.......................................................................................................................10
117690 - MEDICAL WASTE.....................................................................................................................10
117695 - TREATED MEDICAL WASTE.....................................................................................................10
117700 - NOT MEDICAL WASTE.............................................................................................................10
117705 - MEDICAL WASTE GENERATOR................................................................................................11
117710 - MEDICAL WASTE MANAGEMENT PLAN...................................................................................11
117715 - MEDICAL WASTE PERMIT........................................................................................................11
117720 - MEDICAL WASTE REGISTRATION............................................................................................12
117725 - MEDICAL WASTE TREATMENT FACILITY.................................................................................12
117730 - MIXED WASTE.........................................................................................................................12
117735 - OFFSITE.................................................................................................................................12
117740 - ONSITE..................................................................................................................................12
117742 - PARENT ORGANIZATION..........................................................................................................12
117745 - PERSON.................................................................................................................................13
117747 - PHARMACEUTICAL..................................................................................................................13
117750 - SHARPS CONTAINER...............................................................................................................13
117755 - SHARPS WASTE......................................................................................................................13
117760 - SMALL QUANTITY GENERATOR...............................................................................................13
117765 - STORAGE...............................................................................................................................14 January 2007 3
117770 - TRACKING DOCUMENT............................................................................................................14
117775 - TRANSFER STATION................................................................................................................14
117776 - TRAUMA SCENE......................................................................................................................14
117777 - TRAUMA SCENE WASTE..........................................................................................................14
117778 - TRAUMA SCENE WASTE MANAGEMENT PRACTITIONER........................................................14
117780 - TREATMENT............................................................................................................................14
CHAPTER 3 - POWERS AND DUTIES................................................................................................15
117800 - LOCAL AGENCY.......................................................................................................................15
117805 - NOTIFY DEPARTMENT.............................................................................................................15
117810 - IMPLEMENTATION...................................................................................................................15
117815 - PROGRAM CONSISTENCY........................................................................................................15
117820 - MEDICAL WASTE MANAGEMENT PROGRAM...........................................................................15
117825 - REGISTRATION AND PERMIT FEES..........................................................................................16
117830 - ENFORCEMENT AGENCY.........................................................................................................16
117835 - DEPARTMENT’S DATABASE.....................................................................................................16
117840 - INTENT OF THE LEGISLATURE.................................................................................................16
117845 - DEPARTMENT SHALL IMPLEMENT............................................................................................16
117850 - SHARE INFORMATION..............................................................................................................17
117855 - WITHDRAWAL.........................................................................................................................17
117860 - DEPARTMENT BECOMES ENFORCEMENT AGENCY................................................................17
117870 - DEPARTMENT IDENTIFIES SIGNIFICANT VIOLATIONS..............................................................17
117875 - WITHDRAWAL.........................................................................................................................17
117880 - FEES......................................................................................................................................17
117885 - FUND......................................................................................................................................17
117890 - LARGE QUANTITY GENERATOR (LQG) REGISTRATION.........................................................18
117895 - SMALL QUANTITY GENERATOR (SQG) REGISTRATION.........................................................18
117900 - MEDICAL WASTE HAULER REGISTRATION..............................................................................18
117903 - TREAT MEDICAL WASTE.........................................................................................................18
117904 - CONSOLIDATION.....................................................................................................................18
117905 - OFFSITE TREATMENT..............................................................................................................19
117908 - COMMON STORAGE FACILITY.................................................................................................19
117910 - TECHNICAL ASSISTANCE & GUIDANCE...................................................................................19
CHAPTER 4 - SMALL QUANTITY GENERATOR REQUIREMENTS............................................19
117915 - CONTAINMENT AND STORAGE................................................................................................19
117918 - TREATMENT............................................................................................................................19
117920 - REGISTRATION.......................................................................................................................19
117923 - FEES......................................................................................................................................20
117924 - COLLECT FEES........................................................................................................................20
117925 - ONSITE TREATMENT................................................................................................................21
117928 - COMMON STORAGE FACILITY.................................................................................................22
117930 - TREAT ONSITE.........................................................................................................................22
117933 - COMMON STORAGE FACILITY PERMIT....................................................................................22
117935 - MEDICAL WASTE MANAGEMENT PLAN...................................................................................22
117938 - BIENNIAL INSPECTION.............................................................................................................23 January 2007 4
117940 - MEDICAL WASTE GENERATOR REGISTRATION......................................................................23
117943 - TREATMENT AND TRACKING RECORDS..................................................................................23
117945 - INFORMATION DOCUMENTATION AND TRANSPORTATION RECORDS.....................................24
CHAPTER 5 - LARGE QUANTITY GENERATOR REQUIREMENTS............................................24
117950 - REGISTRATION.......................................................................................................................24
117955 - REGISTRATION DATES............................................................................................................24
117960 - MEDICAL WASTE MANAGEMENT PLAN...................................................................................24
117965 - ANNUAL INSPECTION...............................................................................................................25
117970 - MEDICAL WASTE GENERATOR REGISTRATION......................................................................25
117971 – INSPECTION AND ENFORCEMENT COST RECOVERY.............................................................26
117975 - TREATMENT AND TRACKING RECORDS...................................................................................26
117980 - CONTAINMENT AND STORAGE................................................................................................26
117985 - TREATMENT............................................................................................................................26
117990 - FEES......................................................................................................................................26
117995 - COLLECT FEES........................................................................................................................26
CHAPTER 6 - MEDICAL WASTE HAULERS.....................................................................................27
118000 - TRANSPORTATION OF MEDICAL WASTE.................................................................................27
118005 - TRANSPORTATION OF TRAUMA SCENE WASTE......................................................................28
118025 - REGISTRATION.......................................................................................................................29
118027 - UNKNOWINGLY TRANSPORTS.................................................................................................29
118029 - INFORMATION REQUIREMENTS...............................................................................................29
118030 - LIMITED QUANTITY HAULING EXEMPTION (LQHE)................................................................30
118035 - TRANSFER OF MEDICAL WASTE.............................................................................................31
118040 - TRACKING RECORDS...............................................................................................................31
118045 - TRANSFER STATION PERMIT...................................................................................................32
CHAPTER 7 - MEDICAL WASTE TREATMENT FACILITY PERMITS..........................................33
118130 - PERMITS................................................................................................................................33
118135 - PERMIT DATES........................................................................................................................33
118140 - ACCEPTING MEDICAL WASTE.................................................................................................33
118145 - ADJACENT SMALL QUANTITY GENERATORS...........................................................................33
118147 - CONSOLIDATION.....................................................................................................................33
118150 - COMPLIANCE..........................................................................................................................33
118155 - PERMITS................................................................................................................................34
118160 - PERMIT REQUIREMENTS.........................................................................................................34
118165 - TREATMENT RECORDS............................................................................................................35
118170 - DURATION OF PERMIT.............................................................................................................35
118175 - CONDITIONS FOR GRANTING PERMIT.....................................................................................35
118180 - PERMIT VALIDITY.....................................................................................................................36
118185 - PERMIT PROCEDURES.............................................................................................................36
118190 - PERMIT CONDITIONS...............................................................................................................36
118195 - DENIAL OF PERMIT..................................................................................................................36
118200 - INSPECTION............................................................................................................................36
118205 - FEES......................................................................................................................................37 January 2007 5
118210 – COLLECT FEES.......................................................................................................................37
CHAPTER 8 - TREATMENT...................................................................................................................37
118215 - METHODS...............................................................................................................................37
118220 - ANATOMICAL PARTS................................................................................................................39
118222 - WASTE REQUIRING SPECIFIED METHODS..............................................................................39
118225 - SHARPS WASTE......................................................................................................................39
118230 - INCINERATION.........................................................................................................................40
118235 - EMERGENCY ACTION PLAN.....................................................................................................40
118240 - ANIMAL CARCASSES...............................................................................................................40
118245 - FEES FOR ALTERNATIVE TREATMENT TECHNOLOGIES AND MAIL-BACK SYSTEMS...............40
CHAPTER 9 - CONTAINMENT AND STORAGE...............................................................................40
118275 - MEDICAL WASTE SEGREGATION AND STORAGE....................................................................40
118280 - CONTAINMENT AND STORAGE................................................................................................42
118285 - SHARPS WASTE......................................................................................................................43
118286 – MANAGEMENT OF HOME-GENERATED SHARPS WASTE........................................................44
118290 - COMMON STORAGE FACILITY.................................................................................................44
118295 - WASH AND DECONTAMINATE CONTAINERS............................................................................44
118300 - SPILL DECONTAMINATION.......................................................................................................45
118305 - SOLID WASTE..........................................................................................................................45
118307 – INTERIM STORAGE AREA........................................................................................................45
118310 – DESIGNATED ACCUMULATION AREA......................................................................................45
118315 - TRASH CHUTES.......................................................................................................................45
118320 - COMPACTORS OR GRINDERS..................................................................................................46
CHAPTER 9.5 - TRAUMA SCENE WASTE MANAGEMENT..........................................................46
118321 - CITATION OF PART..................................................................................................................46
118321.1 - REGISTRATION AND FEES....................................................................................................47
118321.2 - LIST OF PRACTITIONERS......................................................................................................47
118321.3 - DEPARTMENT DUTIES..........................................................................................................48
118321.4 - TRANSPORTER DEEMED GENERATOR................................................................................48
118321.5 - REMOVAL, TRANSPORTATION, AND STORAGE....................................................................48
118321.6 - LIMITATIONS........................................................................................................................48
CHAPTER 10 - ENFORCEMENT..........................................................................................................49
118325 - INJUNCTION FOR VIOLATIONS.................................................................................................49
118330 - ORDER FOR COMPLIANCE / ADMINISTRATIVE PENALTY.........................................................49
118335 - INSPECTION............................................................................................................................49
118340 - UNAUTHORIZED ACTIONS / CRIMINAL PENALTY.....................................................................50
118345 - FALSE STATEMENTS / FAILURE TO REGISTER........................................................................51
CHAPTER 11 - SUSPENSION OR REVOCATION............................................................................51
118350 - GROUNDS FOR SUSPENSION OR REVOCATION......................................................................51
118355 - PROCEEDINGS........................................................................................................................52
118360 - TEMPORARY PERMIT SUSPENSION.........................................................................................52 January 2007 6
Chapter 1 - General Provisions
117600 - Citation of part
This part shall be known and may be cited as the Medical Waste Management Act.
117605 - Preempt
This part does not preempt any local ordinance regulating infectious waste, as that term was defined by Section 25117.5 as it read on December 31, 1990, if the ordinance was in effect on January 1, 1990, and regulated both large and small quantity generators. Any ordinance may be amended in a manner that is consistent with this part.
117610 - Regulations
The department shall adopt regulations that will establish and ensure statewide standards for uniformity in the implementation and administration of this part and that will promote waste minimization and source reduction.
117615 - Local Ordinance
Notwithstanding Section 117605, with the approval of the director, and in the interest of public health, a local ordinance providing more stringent requirements than specified in this part may be implemented for a specified time period.
117620 - Initiate Program
The department and any local enforcement agency initially electing to implement a medical waste management program pursuant to this part shall initiate that program and begin enforcement of its provisions on or before April 1, 1991, except for medical waste programs operating under Section 117605.
Chapter 2 - Definitions
117625 - Definitions
Unless the context requires otherwise, the definitions in this article govern the construction of this part.
117630 - Biohazard Bag
"Biohazard bag" means a disposable red bag that is impervious to moisture and has a strength sufficient to preclude ripping, tearing, or bursting under normal conditions of usage and handling of the waste-filled bag. A biohazard bag shall be constructed of material of sufficient single thickness strength to pass the 165-gram dropped dart impact resistance test as prescribed by Standard D 1709-85 of the American Society for Testing and Materials and certified by the bag manufacturer.
117635 - Biohazardous Waste
"Biohazardous waste" means any of the following: January 2007 7
(a) Laboratory waste, including, but not limited to, all of the following:
(1) Human or animal specimen cultures from medical and pathology laboratories.
(2) Cultures and stocks of infectious agents from research and industrial laboratories.
(3) Wastes from the production of bacteria, viruses, spores, discarded live and attenuated vaccines used in human health care or research, discarded animal vaccines, including Brucellosis and Contagious Ecthyma, as identified by the department, and culture dishes and de-vices used to transfer, inoculate, and mix cultures.
(b) Human surgery specimens or tissues removed at surgery or autopsy, which are suspected by the attending physician and surgeon or dentist of being contaminated with infectious agents known to be contagious to humans.
(c) Animal parts, tissues, fluids, or carcasses suspected by the attending veterinarian of being contaminated with infectious agents known to be contagious to humans.
(d) Waste, which at the point of transport from the generator’s site, at the point of disposal, or thereafter, contains recognizable fluid blood, fluid blood products, containers or equipment containing blood that is fluid, or blood from animals known to be infected with diseases which are highly communicable to humans.
(e) Waste containing discarded materials contaminated with excretion, exudate, or secretions from humans or animals that are required to be isolated by the infection control staff, the attending physician and surgeon, the attending veterinarian, or the local health officer, to protect others from highly communicable diseases or diseases of animals that are highly communicable to humans.
(f)
(1) Waste which is hazardous only because it is comprised of human surgery specimens or tissues which have been fixed in formaldehyde or other fixatives, or only because the waste is contaminated through contact with, or having previously contained, chemotherapeutic agents, including, but not limited to, gloves, disposable gowns, towels, and intravenous solution bags and attached tubing which are empty. A biohazardous waste which meets the conditions of this paragraph is not subject to Chapter 6.5 (commencing with Section 25100) of Division 20.
(2) For purposes of this subdivision, "chemotherapeutic agent" means an agent that kills or prevents the reproduction of malignant cells.
(3) For purposes of this subdivision, a container, or inner liner removed from a container, which previously contained a chemotherapeutic agent, is empty if the January 2007 8
container or inner liner removed from the container has been emptied by the generator as much as possible, using methods commonly employed to remove waste or material from containers or liners, so that the following conditions are met:
(A) If the material which the container or inner liner held is pourable, no material can be poured or drained from the container or inner liner when held in any orientation, including, but not limited to, when tilted or inverted.
(B) If the material which the container or inner liner held is not pourable, no material or waste remains in the container or inner liner that can feasibly be removed by scraping.
(g) Waste that is hazardous only because it is comprised of pharmaceuticals, as defined in Section 117747. Notwithstanding subdivision (a) of Section 117690, medical waste includes biohazardous waste that meets the conditions of this subdivision. Biohazardous waste that meets the conditions of this subdivision is not subject to Chapter 6.5 (commencing with Section 25100) of Division 20.
117640 - Common Storage Facility
"Common storage facility" means any designated accumulation area that is onsite and is used by small quantity generators otherwise operating independently for the storage of medical waste for collection by a registered hazardous waste hauler.
117645 - Container
"Container" means the rigid container in which the medical waste is placed prior to transporting for purposes of storage or treatment.
117650 - Enforcement Agency
"Enforcement agency" means the department or the local agency administering this part.
117655 - Enforcement Officer
"Enforcement officer" means the director, or agents or registered environmental health specialists appointed by the director, and all local health officers, directors of environmental health, and their duly authorized registered environmental health specialists and environmental health specialist trainees, or the designees of the director, local health officers, or the directors of environmental health.
117657 - Fund
"Fund" means the Medical Waste Management Fund created pursuant to Section 117885.
117660 - Hazardous Waste Hauler
"Hazardous waste hauler" means a person registered as a hazardous waste hauler pursuant to Article 6 (commencing with Section 25160) and Article 6.5 (commencing with Section 25167.1) of Chapter 6.5 of Division 20 and Chapter 30 (commencing with Section 66001) of Division 4 of Title 22 of the California Code of Regulations. January 2007 9
117662 - Health Care Professional
"Health care professional" means any person licensed or certified pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code; any person licensed pursuant to the Osteopathic Initiative Act, as set forth in Chapter 8 (commencing with Section 3600) of Division 2 of the Business and Professions Code, or pursuant to the Chiropractic Initiative Act, as set forth in Chapter 2 (commencing with Section 1000) of Division 2 of the Business and Professions Code; and any person certified pursuant to Division 2.5 (commencing with Section 1797).
117665 - Highly Communicable Diseases
"Highly communicable diseases" means diseases, such as those caused by organisms classified by the federal Centers for Disease Control as Biosafety Level IV organisms, that, in the opinion of the infection control staff, the department, local health officer, attending physician and surgeon, or attending veterinarian, merit special precautions to protect staff, patients, and other persons from infection. "Highly communicable diseases" does not include diseases such as the common cold, influenza, or other diseases not representing a significant danger to nonimmunocompromised persons.
117670 - Household Waste
"Household waste" means any material, including garbage, trash, and sanitary wastes in septic tanks and medical waste, that is derived from households, farms, or ranches. Household waste does not include trauma scene waste.
117671 – Home-generated Sharps Waste
"Home-generated sharps waste" means hypodermic needles, pen needles, intravenous needles, lancets, and other devices that are used to penetrate the skin for the delivery of medications derived from a household, including a multifamily residence or household.
117672 - Industrial Hygienist
"Industrial hygienist" means a person who has met the educational requirements of an industrial hygiene certification organization, as defined in subdivision (c) of Section 20700 of the Business and Professions Code, and who has had at least one year in the comprehensive practice of industrial hygiene, as defined in subdivision (a) of Section 20700 of the Business and Professions Code.
117675 - Infectious Agent
"Infectious agent" means a type of microorganism, bacteria, mold, parasite, or virus, including, but not limited to, organisms managed as Biosafety Level II, III, or IV by the federal Centers for Disease Control and Prevention, that normally causes, or significantly contributes to the cause of, increased morbidity or mortality of human beings.
117680 - Large Quantity Generator
"Large quantity generator" means a medical waste generator, other than a trauma scene waste management practitioner, that generates 200 or more pounds of medical waste in any month of a 12-month period. January 2007 10
117685 - Local Agency
"Local agency" means the local health department, as defined in Section 101185, or the local comprehensive environmental agency established in accordance with Section 101275, of a county that has elected to adopt a local ordinance to administer and enforce this part, pursuant to Chapter 3 (commencing with Section 117800).
117690 - Medical Waste
(a) "Medical waste" means waste which meets both of the following requirements:
(1) The waste is composed of waste which is generated or produced as a result of any of the following actions:
(A) Diagnosis, treatment, or immunization of human beings or animals.
(B) Research pertaining to the activities specified in subparagraph (A).
(C) The production or testing of biologicals.
(D) The accumulation of properly contained home-generated sharps waste that is brought by a patient, a member of the patient’s family, or by a person authorized by the enforcement agency, to a point of consolidation approved by the enforcement agency pursuant to Section 117904 or authorized pursuant to Section 118147.
(E) Removal of a regulated waste, as defined in Section 5193 of Title 8 of the California Code of Regulations, from a trauma scene by a trauma scene waste management practitioner.
(2) The waste is either of the following:
(A) Biohazardous waste.
(B) Sharps waste.
(b) For purposes of this section, "biologicals" means medicinal preparations made from living organisms and their products, including, but not limited to, serums, vaccines, antigens, and anti-toxins.
(c) Medical waste includes trauma scene waste.
117695 - Treated Medical Waste
Medical waste that has been treated in accordance with Chapter 8 (commencing with Section 118215) and that is not otherwise hazardous, shall thereafter be considered solid waste as defined in Section 40191 of the Public Resources Code and not medical waste.
117700 - Not Medical Waste
Medical waste does not include any of the following: January 2007 11
(a) Waste generated in food processing or biotechnology that does not contain an infectious agent as defined in Section 117675.
(b) Waste generated in biotechnology that does not contain human blood or blood products or animal blood or blood products suspected of being contaminated with infectious agents known to be communicable to humans.
(c) Urine, feces, saliva, sputum, nasal secretions, sweat, tears, or vomitus, unless it contains fluid blood, as provided in subdivision (d) of Section 117635.
(d) Waste which is not biohazardous, such as paper towels, paper products, articles containing nonfluid blood, and other medical solid waste products commonly found in the facilities of medical waste generators.
(e) Hazardous waste, radioactive waste, or household waste, including, but not limited to, home-generated sharps waste, as defined in Section 117671.
(f) Waste generated from normal and legal veterinarian, agricultural, and animal livestock management practices on a farm or ranch.
117705 - Medical Waste Generator
"Medical waste generator" means any person whose act or process produces medical waste and includes, but is not limited to, a provider of health care, as defined in subdivision (d) of Section 56.05 of the Civil Code. All of the following are examples of businesses that generate medical waste:
(a) Medical and dental offices, clinics, hospitals, surgery centers, laboratories, research laboratories, unlicensed health facilities, those facilities required to be licensed pursuant to Division 2 (commencing with Section 1200), chronic dialysis clinics, as regulated pursuant to Division 2 (commencing with Section 1200), and education and research facilities.
(b) Veterinary offices, veterinary clinics, and veterinary hospitals.
(c) Pet shops.
(d) Trauma scene waste management practitioners.
117710 - Medical Waste Management Plan
"Medical waste management plan" means a document that is completed by generators of medical waste pursuant to Sections 117935 and 117960, on forms prepared by the enforcement agency.
117715 - Medical Waste Permit
"Medical waste permit" means a permit issued by the enforcement agency to a medical waste treatment facility. January 2007 12
117720 - Medical Waste Registration
"Medical waste registration" means a registration issued by the enforcement agency to a
medical waste generator.
117725 - Medical Waste Treatment Facility
(a) "Medical waste treatment facility" means all adjacent land and structures, and other appurtenances or improvements on the land, used for treating medical waste or for associated handling and storage of medical waste. Medical waste treatment facilities are those facilities treating waste pursuant to subdivision (a) or (c) of Section 118215. A medical waste treatment method approved pursuant to subdivision (d) of Section 118215 may be designated as a medical waste treatment facility by the department.
(b) "Adjacent," for purposes of subdivision (a), means real property within 400 yards from the property boundary of the existing medical waste treatment facility.
117730 - Mixed Waste
"Mixed waste" means mixtures of medical and non-medical waste. Mixed waste is medical waste, except for all of the following:
(a) Medical waste and hazardous waste is hazardous waste and is subject to regulation as specified in the statutes and regulations applicable to hazardous waste.
(b) Medical waste and radioactive waste is radioactive waste and is subject to regulation as specified in the statutes and regulations applicable to radioactive waste.
(c) Medical waste, hazardous waste, and radioactive waste is radioactive mixed waste and is subject to regulation as specified in the statutes and regulations applicable to hazardous waste and radioactive waste.
117735 - Offsite
"Offsite" means any location that is not onsite.
117740 - Onsite
(a) "Onsite" means a medical waste treatment facility, or common storage facility on the same or adjacent property as the generator of the medical waste being treated.
(b) "Adjacent," for purposes of subdivision (a), means real property within 400 yards from the property boundary of the existing medical waste treatment facility.
117742 - Parent Organization
"Parent organization" means an organization that employs or contracts with health care professionals who provide health care services at a location other than at a health care facility specified in subdivision (a) of Section 117705. January 2007 13
117745 - Person
"Person" means an individual, trust, firm, joint stock company, business concern, partnership, association, limited liability company, and corporation, including, but not limited to, a government corporation. "Person" also includes any city, county, district, commission, the state or any department, agency, or political subdivision thereof, the Regents of the University of California, any interstate body, and the federal government or any department or agency thereof to the extent permitted by law.
117747 - Pharmaceutical
(a) "Pharmaceutical" means a prescription or over-the-counter human or veterinary drug, including, but not limited to, a drug as defined in Section 109925 or the Federal Food, Drug, and Cosmetic Act, as amended, (21 U.S.C.A. Sec. 321(g)(1)).
(b) For purposes of this part, "pharmaceutical" does not include any pharmaceutical that is regulated pursuant to either of the following:
(1) The federal Resource Conservation and Recovery Act of 1976, as amended (42 U.S.C.A. Sec. 6901 et seq.).
(2) The Radiation Control Law (Chapter 8 [commencing with Section 114960] of Part 9).
117750 - Sharps Container
"Sharps container" means a rigid puncture-resistant container that, when sealed, is leak resistant and cannot be reopened without great difficulty.
117755 - Sharps Waste
"Sharps waste" means any device having acute rigid corners, edges, or protuberances capable of cutting or piercing, including, but not limited to, all of the following:
(a) Hypodermic needles, hypodermic needles with syringes, blades, needles with attached tubing, syringes contaminated with biohazardous waste, acupuncture needles, and root canal files.
(b) Broken glass items, such as Pasteur pipettes and blood vials contaminated with biohazardous waste.
(c) Any item capable of cutting or piercing that is contaminated with trauma scene waste.
117760 - Small Quantity Generator
"Small quantity generator" means a medical waste generator, other than a trauma scene waste management practitioner, that generates less than 200 pounds per month of medical waste. January 2007 14
117765 - Storage
"Storage" means the holding of medical wastes, in accordance with Chapter 9 (commencing with Section 118275), at a designated accumulation area, offsite point of consolidation, transfer station, other registered facility, or in a vehicle detached from its means of locomotion.
117770 - Tracking Document
"Tracking document" means the medical waste tracking document specified in Section 118040.
117775 - Transfer Station
(a) "Transfer station" means any offsite location where medical waste is loaded, unloaded, stored, or consolidated by a registered hazardous waste hauler, or a holder of a limited quantity hauling exemption granted pursuant to Section 118030, during the normal course of transportation of the medical waste.
(b) "Transfer station" does not include any onsite facility, including, but not limited to, common storage facilities, facilities of medical waste generators employed for the purpose of consolidation, or onsite treatment facilities.
117776 - Trauma Scene.
(a) "Trauma scene" means a location soiled by, or contaminated with, human blood, human body fluids, or other residues from the scene of a serious human injury, illness, or death.
(b) For purposes of this section, a location may include, but is not limited to, a physical structure that is not fixed geographically, such as mobile homes, trailers, or vehicles.
117777 - Trauma Scene Waste
"Trauma scene waste" means waste that is a regulated waste, as defined in Section 5193 of Title 8 of the California Code of Regulations, and that has been removed, is to be removed, or is in the process of being removed, from a trauma scene by a trauma scene waste management practitioner.
117778 - Trauma Scene Waste Management Practitioner
"Trauma scene waste management practitioner" means a person who undertakes as a commercial activity the removal of human blood, human body fluids, and other associated residues from the scene of a serious human injury, illness, or death, and who is registered with the department pursuant to Chapter 9.5 (commencing with Section 118321).
117780 - Treatment
"Treatment" means any method, technique, or process designed to change the biological character or composition of any medical waste so as to eliminate its potential for causing disease, as specified in Chapter 8 (commencing with Section 118215). January 2007 15
United States
Environmental Protection
Agency
Technology Transfer
Office of
Research and Development
Washington DC 20460
EPA/625/7-90/009
June 1990
Guides to Pollution
Prevention
Selected Hospital Waste
Streams
EPA/625/7-90/009
June 1990
GUIDES TO POLLUTION PREVENTION:
SELECTED HOSPITAL WASTE STREAMS
RISK REDUCTION ENGINEERING LABORATORY
CENTER FOR ENVIRONMENTAL RESEARCH INFORMATION
OFFICE OF RESEARCH AND DEVELOPMENT
U.S. ENVIRONMENTAL PROTECTION AGENCY
CINCINNATI, OHIO 45268
Printed on Recycled Paper
NOTICE
This guide has been subjected to U.S. Environmental Protection Agency’s peer and
administrative review, and approved for publication. Approval does not signify that
the contents necessarily reflect the views and policies of the U.S. Environmental
Protection Agency, nor does mention of trade names or commercial products
constitute endorsement or recommendation for use. This document is intended as
advisory guidance only to hospitals in developing approaches for pollution prevention.
Compliance with environmental and occupational safety and health laws is the
responsibility of each individual medical institution and is not the focus of this
document.
Worksheets are provided for conducting waste minimization assessments of hospital
facilities. Users are encouraged to duplicate portions of this publication as needed
to implement a waste minimization program.
ii
FOREWORD
This guide provides an overview of hospital waste generating processes and
presents options for minimizing waste generation through source reduction and
recycling. Reducing the generation of these materials at the source, or recycling
the wastes on or off site, will benefit hospitals by reducing disposal costs and
lowering the liabilities associated with hazardous waste disposal.
The hazardous wastes generated by general medical and surgical hospitals are small
in volume relative to those of industrial facilities; however, the wastes are of a wide
variety. Some of the hazardous materials used by hospitals that become part of their
waste streams include chemotherapy and antineoplastic chemicals; solvents;
formaldehyde; photographic chemicals; radionuclides; mercury; waste anesthetic
gases; and other toxic, corrosive and miscellaneous chemicals. Additional wastes
such as infectious waste, incinerator exhaust, laundry-related waste, utility wastes,
and trash are not addressed in this guide.
I. .l l.
ACKNOWLEDGMENTS
This guide is based in part on waste minimization assessments conducted by
Ecological and Environment, Inc. for the California Department of Health Services
(DHS). Contributors to these assessments include: Benjamin Fries, and Eric
Workman of the Alternative Technology Section of DHS. Jacobs Engineering
Group Inc. edited and developed this version of the waste minimization assessment
guide, under subcontract to Radian Corporation (USEPA Contract 68-02-4286).
Jacobs personnel contributing to this guide include: Carl Fromm, project manager;
Michael Callahan, Sally Lawrence, and Andrew Nelson, project group members.
Lisa M. Brown of the U.S. Environmental Protection Agency, Office of Research
and Development, Risk Reduction Engineering Laboratory, was the project
officer responsible for the preparation and review of this guide. Other contributors
and reviewers include: Mark Ellefson, Health and Safety, University of Washington;
M.C. Hull, Chemical Safety Officer, Research and Occupational Safety, University
of California- Los Angeles; and Michael Todd, Assistant Manager of Engineering,
Huntington Memorial Hospital, Pasadena. Information about waste anesthesia
gases, ethylene oxide, and mercury recyclers was provided by ECRI, publisher of
Hospital Hazardous Materials Management (TM)
iv
CONTENTS
SECTION PAGE
Notice .................................................................................................................. ii
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
Acknowledgments ....................................................................................................................................................... iv
1. Introduction ........................................................................................................................................................... 1
2. Hospital Waste Profile .......................................................................................................................................... 5
3. Waste Minimization Options ................................................................................................................................ 9
4. Guidelines for Using the Waste Minimization Worksheets.. ............................................................................... 18
Appendix A:
Facility Assessments of Three Hospitals ............................................................................................................ .33
Appendix B:
Where to Get Help: Further Information on Waste Minimization ..................................................................... .41
V
considered preferable to recycling from an environmental
perspective.
A Waste Minimization Opportunity Assessment
(WMOA), sometimes called a waste minimization audit, is
a systematic procedure for identifying ways to reduce or
eliminate waste. The steps involved in conducting a waste
minimization assessment are outlined in Figure 1 and
presented in more detail in the next paragraphs. Briefly, the
assessment consists of a careful review of an institution’s
operations and waste streams and the selection of specific
areas to assess. After a particular waste stream or area is
established as the WMOA focus, a number of options with
the potential to minimize waste are developed and screened.
The technical and economic feasibility of the selected
options are then evaluated. Finally, the most promising
options are selected for implementation.
To determine whether a WMOA would be useful in
your circumstances, you should first read this section
describing the aims and essentials of the WMOA process.
For more detailed information on conducting a WMOA,
consult the Waste Minimization Opportunity Assessment
Manual.
ASSESSMENT PROCESS
The four phases of a waste minimization assessment,
described briefly below, are:
Planning and organization
Assessment phase
Feasibility analysis phase
Implementation
Planning and Organization
Essential elements of planning and organization for a
waste minimization program are: getting management
commitment for the program; setting waste minimization
goals; and organizing an assessment program task force.
The importance of getting management support for waste
minimization cannot be overstated.
Assessment Phase
The assessment phase involves a number of steps:
l Collect process and facility data
l Prioritize and select assessment targets
l Select assessment team
l Review data and inspect site
l Generate options
l Screen and select options for feasibility study
Collect process and facility data. The waste streams at the
facility should be identified and characterized. Information
about waste streams may be available on hazardous waste
manifests, lab pack packing lists, National Pollutant
Discharge Elimination System (NPDES) reports, routine
sampling programs and other sources.
Developing a basic understanding of the activities that
generate waste at a hospital facility is essential to the
WMOA process. Flow diagrams should be prepared to
identify the quantity, types and rates of waste generating
activities. Also, preparing material balances for various
processes can be useful in tracking various process
components and identifying losses that may have been
unaccounted for previously. This may be especially useful
when attempting to differentiate between infectious and
hazardous wastes.
Prioritize and select assessment targets. Ideally, all waste
streams in a facility should be evaluated for potential waste
minimization opportunities. However, with limited
resources, a hospital administrator may need to concentrate
waste minimization efforts in a specific area. Such
considerations as quantity of waste, hazardous properties
of the waste, regulations, safety of employees, economics,
and other characteristics need to be evaluated in selecting
a target stream.
Select assessment team. The team should include people
with direct responsibility for and knowledge of the waste
streams or activities that generate the wastes. Use of
consultants should be considered when nointernal expertise
is available.
Review data and inspect site. The assessment team evaluates
activity data in advance of the site inspection. Theinspection
should follow the target activities from the point where raw
materials enter the facility to the points where wastes leave.
The team should identify the suspected and known sources
of waste. For hazardous waste this may include laboratories,
pharmacies, pathology, radiology, surgery, dialysis,
embalming, nursing units, nuclear medicine, mercury from
broken or obsolete equipment, “red bag” (infectious) wastes;
maintenanceoperations; and storage areas for raw materials
and wastes. The inspection may result in the formation of
preliminary conclusions about waste minimization
opportunities. Full confirmation of these conclusions may
require additional data collection or analysis.
Generate options. The objective of this step is to generate
a comprehensive set of waste minimization options for
further consideration. Since technical and economic concerns
will be considered in the later feasibility step, no
options should be ruled out at this stage. Information from
the site inspection, as well as medical associations,
government agencies, technical and medical reports, equip
ment vendors, consultants, and facility engineers and technicians
may serve as sources of ideas for waste minimization
options.
Both source reduction and recycling options should be
considered. Source reduction approaches include:
Good operating practices
Eliminating or reducing use of carcinogenic
chemicals such as benzene and chloroform
Increased use of analytical instrumentation -
this can decrease the use of chemicals
Improved inventory control utilizing
computerized tracking and inventory systems,
also use of central purchasing
Elimination of use of oil based paints in
maintenance
Recycling includes:
Use and reuse of waste
Reclamation
Screen and select options for further study. This screening
process is intended to select the most promising options for
full technical and economic feasibility study. Through
either an informal review or a quantitative decision-making
process, options that appear marginal, impractical or
inferior are eliminated from consideration.
Feasibility Analysis
An option must be shown to be technically and
economically feasible in order to merit serious consideration
for adoption. A technical evaluation determines whether a
proposed option will work in a specific application. Both
operational and equipment changes need to be assessed for
their overall effects on waste quantity. Also, any new
products or raw materials need to be tested for efficacy.
An economic evaluation is carried out using standard
measures of profitability, such as payback period, return on
investment, and net present value. As in any project, the
cost elements of a waste minimization project can be
broken down into capital costs and operating costs. Savings
and changes in revenue need also to be considered.
Implementation
An option that passes both technical and economic
feasibility reviews should then be implemented. It is then
up to the WMOA team, with management support, to
continue the process of tracking wastes and identifying
future opportunities for waste minimization throughout a
facility by way of periodic reassessments. Both the ongoing
reassessments and an initial investigation of waste minimization
opportunities can be conducted using this guide.
4
SECTION 2
HOSPITAL WASTE PROFILE
Hospital hazardous waste is unique in several ways.
There is a large variety of wastes but the volumes are small
relative to industrial facilities. Hospitals employ toxic
chemicals and hazardous materials for numerous diagnostic
and treatment purposes. The hazardous materials include:
. Chemotherapy and antineoplastic chemicals
Formaldehyde
Photographic chemicals
Radionuclides
Solvents
Mercury
Waste anesthetic gases
Other toxic, corrosive, and miscellaneous
chemicals
Based on audits of three hospitals conducted for this
study, chemotherapy wastes, including concentrated
antineoplastic chemicals mixed with other inert materials,
represented the highest volume of hazardous waste at each
hospital. This was followed by spent photographic
chemicals and formaldehyde solutions used for disinfecting
equipment. Other significant and potentially significant
sources of hazardous wastes noted were solvents,
radioactive wastes, mercury, waste anesthetic gases and
other toxics and corrosives. The scope of the assessments
did not include infectious waste, incinerator exhaust,
laundry-related waste, utility waste and trash,
Waste Description
CHEMOTHERAPY AND ANTINEOPLASTIC
CHEMICALS
Procurement of antineoplastic, or cytotoxic, agents
that are used to produce chemotherapy solutions is generally
conducted through a central clinic or pharmacy. Quantities
kept on hand at the hospitals audited were generally
sufficient to last less than two weeks. Chemicals are mixed
or compounded within a hood, which recirculates air
through a filter. Chemotherapy wastes account for the
largest volume of hazardous wastes produced by surveyed
hospitals. Only a small percentage of these wastes
contain concentrated amounts of chemotherapy
compounds. Much of the waste volume is associated
with lightly contaminated items such as personal
protective clothing and gauze pads. Sharp items such as
needles (“sharps”) are also discarded, but may be
separated and handled as infectious waste.
Waste materials are placed into plastic bags or
plastic containers that are either replaced daily, or when
they are full. An average of 2 to 8 cubic feet of
chemotherapy wastes per week were generated by the
hospitals surveyed. These wastes are either transported
off-site to a Class I landfill or incinerated as infectious
waste. However, it should be noted that the latter may
not be an acceptable alternative under some state
hazardous waste regulations. Landfilling of hazardous
wastes is discouraged or prohibited in many areas of the
country and should not generally be considered a viable
disposal option for hospital hazardous wastes.
FORMALDEHYDE
Formaldehyde is used in pathology, autopsy, dialysis,
embalming, and nursing units. Occupational exposure to
airbone concentrations of formaldehyde is regulated by
OSHA. New regulations limit the permissible exposure
to 1.0 ppm as an 8-hour time weighted average (TWA),
with an action level of 0.5 ppm (ECRI, Jan, 1988).
Formaldehyde also represents a significant source
of hazardous waste at many hospitals. For use in dialysis,
formaldehyde is generally purchased as a 37 percent
formaldehyde-in-water solution (formalin). It is
subsequently diluted with filtered, deionized water to
achieve a final formaldehyde concentration of 24 percent.
The formalin is either pumped or poured into dialysis
machines to disinfect the membranes and the effluent is
discharged to the sewer. In other departments,
formaldehyde is generally used to preserve specimens
with small quantities of waste generated and discharged
to the sewer. Discharging a hazardous material to the
sewer may be illegal and is generally an undesirable
management practice, even if sanitation authorities allow
such disposal.
5
as hazardous waste. If there is no scavenging unit, or if the
scavenging unit does not have a filter, then vacuum lines
are used to collect waste anesthetic gases and vent them to
the outside.
TOXICS, CORROSIVES, AND MISCELLANEOUS
CHEMICALS
Poisons, oxidizers, and caustics are used throughout
most hospitals, generally in small quantities. Waste oils
and solvents from maintenance may also be considered
hazardous wastes as may some boiler water conditioning
chemicals. Although many of these types of wastes are
considered hazardous materials, only ethylene oxide was
used at the surveyed hospitals in large quantities. All of the
audited hospitals currently discharge this gas to the
atmosphere but may soon be required to treat it. Many
facilities in California are already required to “scrub” these
emissions.
Listed below are some major toxic, corrosive, and
miscellaneous chemical wastes and their sources of origin:
Ethylene Oxide Used in sterilizers. Classified
by EPA as a probable human
carcinogen; also a smog
forming agent, and
explosive/flammability
hazard.
Disinfecting Cleaning
Solutions
Utility Wastes
Maintenance Wastes
Phenol based, used for
scrubbing floors and other
applications.
Boiler feed water treatment
residuals (resin regeneration
brine, spent resin)
Boiler blowdown
Boiler cleaning (layup) wastes
Cooling tower blowdown
Cooling tower sludges/
sediments
Waste lube oils, vacuum pump
oils
Cleaning solvents
Paint stripping wastes
Leftover paints and painting
accessories
Spent fluorescent lamps
Ethylene Oxide
Ethylene oxide(EtO), used to sterilizemedical devices,
is used in central supply areas, respiratory therapy, and at
times, in operating rooms. This colorless and odorless gas
can cause a number of acute toxic reactions and is a
probable human carcinogen (ECRI Jan. 1989).
Ethylene oxide is purchased in cartridges or cylinders
that can be attached directly to specially designed
sterilizers. Equipment that has been sterilized in a Et0
sterilizer is transferred to an Et aeration chamber. Both
Et0 sterilizers and aerators are connected to ventilation
systems which duct the exhaust to the outside. Used
ethylene oxide cylinders are returned to the supplier.
Some hospitals are going to bulk storage of ethylene
oxide, using large tanks.
Waste Management Issues
A large variety of hazardous materials is used in
hospitals; however, overall waste quantities generated
are relatively low. Tracking of hazardous wastes in
hospitals is often complicated by a lack of available
records on waste generation. This results from hazardous
wastes being mixed with infectious wastes and from
disposal of potentially hazardous wastes into the sewer.
The Medical Waste Tracking Act is a demonstration
program (participants are New York, New Jersey,
Connecticut, Rhode Island, Louisiana, and the District
of Columbia) that will require generators of more than 50
pounds of waste monthly to use a four-copy manifest
tracking system. Included in “medical waste”, for the
purposes of the Act, will be cultures and stocks of
infectious agents and associated biologicals; pathological
waste; human blood and blood products; used sharps;
contaminated animal carcasses; surgery or autopsy waste;
laboratory wastes; dialysis wastes: discarded medical
equipment; and isolation wastes.
MWTA is expected to lead eventually to a broader
tracking program that will affect all states. It may also
provide impetus to hospitals to incinerate many types of
waste on site. With this possibility in view, EPA expects
to establish medical waste incineration regulations under
the Clean Air Act (Roy 1989).
INFECTIOUS WASTES
Although recently awareness has increased regarding
the need for proper disposal of medical waste, there has
been a misconception at some hospitals regarding the
need to apply proper hazardous waste disposal practices
for wastes containing both infectious and hazardous
components. By current law, any waste mixture of nonhazardous
and hazardous or infectious and hazardous
wastes must be handled as a hazardous waste. Many
items that are routinely handled as infectious waste
(gauze pads, gowns, etc. that are contaminated with
hazardous waste) should be handled as hazardous waste.
The lack of manifesting requirements for infectious
wastes makes accurate determinations of hazardous
components in these waste streams even more difficult.
The generation and disposal of infectious wastes were
excluded from the scope of the assessments.
SEWER USE AND PRETREATMENT
The diluted nature and/or low volume of certain
hazardous liquid wastes has resulted in some hospitals
obtaining permission from the local sanitary district to
discharge these solutions to the sewer. For instance,
formaldehyde solutions from dialysis and pathology
departments are routinely discharged to the sewer. Wastes
from these departments contain between 4 and 10 percent
formaldehyde, respectively. Permission by the sanitary
districts to discharge these wastes to the sewer is normally
granted only for non-bioaccumulative wastes.
SECTION 3
WASTE MINIMIZATION OPTIONS
Description of Techniques
This section discusses recommended waste
minimization methods for general medical and surgical
hospitals. These methods were identified through waste
minimization assessments of hospitals and through
reference to technical literature. Hospitals’ primary waste
streams are listed in Table 1 along with recommended
control methods. Infectious wastes, incinerator exhaust,
laundry-related waste, utility wastes and trash are not
addressed. The control methods can be classified generally
as sourcereduction methods which can be achieved through
material substitution, process or equipment modification,
or better operating practices; or as recycling. Treatment of
hazardous waste is not the focus of this guide.
l Assure that the identity of all chemical and
wastes is clearly marked on all containers.
Improved management and control practices include:
Centralize purchasing anddispensing of drugs
and other hazardous chemicals.
Monitor drug and chemical flows within the
facility from receipt as raw materials to
disposal as hazardous wastes. This may be
partially or fully automated by the use of
computer systems and computer-readable
barcoded labels for incoming chemicals,
similar to those used in supermarkets.
l Apportion waste management costs to the
The waste minimization options are presented for
specific waste streams, following a discussion of better
operating practices that can be used in overall hospital
waste management.
.
Better Operating Practices
Better operating practices are procedures and
institutional policies that result in a reduction of waste.
Improved management oversight, tracking, and inventory
control can effectively reduce waste generation.
Computerized data base tracking systems provide a very
effective and efficient method of tracking and inventory
control.
.
Key overall operating strategies include:
Keep individual waste streams segregated.
- Keep hazardous waste segregated from
nonhazardous waste. All waste
contaminated with a hazardous substance
becomes hazardous.
- Keep hazardous chemical wastes
segregated from infectious wastes,
- Keep recyclable waste segregated from
non-recyclable waste.
.
. Minimize dilution of hazardous waste.
departments that generate the wastes.
Improve inventory control by:
- Requiring users of chemicals with limited
shelf life to use up old stock before ordering
or using new stock.
- Ordering hazardous chemicals only when
needed and in minimal quantities to avoid
outdated inventory.
Provide employee training in hazardous
materials management and waste
minimization. The major generating
departments should have a training program
for all staff who may generate or handle
hazardous materials. Training should include:
- Chemical hazards.
- Spill prevention.
- Preventive maintenance.
- Emergency preparedness and
response, including spill clean-up.
Implement an institution-wide waste
reduction program.
9
Table 1. Waste Minimization Methods for General Medical and Surgical Hospitals
Waste Category Waste Minimization Method
Chemotherapy and
Antineoplastics
Formaldehyde
Photographic Chemicals
Radionuclides
Solvents
Reduce volumes used.
Optimize drug container sizes in purchasing.
Return outdated drugs to manufacturer.
Centralize chemotherapy compounding location.
Minimize waste from compounding hood cleaning.
Provide spill cleanup kits.
Segregate wastes.
Minimize strength of formaldehyde solutions.
Minimize wastes from cleaning of dialysis machines and RO units.
Use reverse osmosis water treatment to reduce dialysis cleaning
demands.
Capture waste formaldehyde.
Investigate reuse in pathology, autopsy laboratories.
Return off-spec developer to manufacturer.
Cover developer and fixer tanks to reduce evaporation, oxidation.
Recover silver efficiently.
Recycle waste film and paper.
Use squeegees to reduce bath losses.
Use countercurrent washing.
Use less hazardous isotopes whenever possible.
Segregate and properly label radioactive wastes, and store short-lived
radioactive wastes in isolation on site until decay permits disposal in
trash.
Substitute less hazardous cleaning agents, methods for solvents
cleaners.
Mercury
Waste Anesthetic Gases
Toxics, Corrosives and
Miscellaneous Chemicals
Reduce analyte volume requirements.
Use pre-mixed kits for tests involving solvent fixation.
Use calibrated solvent dispensers for routine tests.
Segregate solvent wastes.
Recover/reuse solvents through distillation.
Substitute electronic sensing devices for mercury-containing devices.
Provide mercury spill cleanup kits and train personnel.
. Recycle uncontaminated mercury wastes using proper safety controls.
Employ low leakage work practices.
Purchase low-leakage equipment.
Maintain equipment properly to avoid leaks.
Inspection and proper equipment maintenance for ethylene oxide
sterilizers.
Substitute less toxic compounds, cleaning agents.
Reduce volumes used in experiments.
Return containers for reuse, use recyclable drums.
Neutralize acid waste with basic waste.
Use mechanical handling aids for drums to reduce spills.
Use automated systems for laundry chemicals.
Use physical instead of chemical cleaning methods.
10
discharged to the sewer. Ways to minimize this waste
include installation of reverse osmosis water supply
equipment, using minimium effective cleaning procedures,
recycling and reusing waste solutions, and proper waste
management.
Install Reverse Osmosis (RO) Water
Supply Equipment.
Since the cleaning of dialysis equipment is the major
reason for formaldehyde waste, any measures that help to
reduce the need for cleaning will help reduce waste
generation. Hospitals reported that use of RO units allows
a reduction in the cleaning frequency requirements of
dialysis machines. While RO water treatment units also
are typically flushed with formalin, they can be cleaned
instead with hydrogen peroxide, which is less persistent in
the environment.
Determine Minimum Effective Cleaning Procedures.
At the surveyed hospitals, a significant variation was
observed in the cleaning frequency of the hemodialysis
machines and of the reverse osmosis (RO) water supply
equipment. Since waste generation rates are directly
related to cleaning frequency and formalin strength, the
potential exists for minimizing these wastes by optimizing
both variables. There is an apparent need to develop
consistent standards for formalin solutions, based upon
microbial culture studies. These studies should compare
microbial residues with variations in formalin strength,
cleaning frequency, and water supply systems.
Reuse/Recycle Waste Solutions.
The diluted formalin waste stream contains
approximately 4 percent formaldehyde, 1 percent methanol,
and 95 percent water. Surplus or absolute dialysis units
could possibly be used to concentrate the formaldehyde for
reuse. Dialysis has been used to recover organic material
in rayon manufacturing (Sawyer and McCarty 1967). Offspec
dialysis membranes could possibly be used to extract
and concentrate the formaldehyde wastes for eventual
reuse, recycle, or incineration.
Recovery of waste formalin through distillation is also
theoretically feasible. However, none of the surveyed
hospitals is recycling formaldehyde wastes through
distillation. The tendency for formaldehyde to polymerize
and form azeotropes with water and methanol may affect
recovery efficiencies. Moreover, a high purity extract is
required for reuse in dialysis to ensure that there are no
pathogenic contaminants in the aqueous fraction. For these
reasons, distillation would need to be monitored carefully.
In autopsy and pathology laboratories, depending upon the
type of specimen, direct reuse of formaldehyde solutions
may be feasible. These solutions retain their desired
properties for periods far longer than the usual holding
times for specimens. In addition, the desired preservative
properties may be effective at lower concentrations than
the 10 percent formaldehyde solutions typically used.
Reuse of hospital formaldehyde wastes through an openmarket
waste exchange does not appear feasible. This is
because of the potential presence of pathogens in the
waste stream.
Proper Waste Management.
All waste management methods should stress control
of airborne emissions since formaldehyde is a suspected
carcinogen of the upper respiratory system (ACGIH
1987). The OSHA permissible exposure level (PEL) for
formaldehyde was recently reduced from 10 ppm to 1
ppm.
PHOTOGRAPHIC CHEMICAL WASTE
The major waste stream associated with image
processing at hospital radiology departments is
wastewater that contains photographic chemicals and
silver removed from film. Other wastes include spoiled
chemicals and scrap film. Ways to reduce these wastes
include:
Store Materials Properly.
Many photoprocessing chemicals are sensitive to
temperature and light. Photosensitive film and paper
storage areas should be designed for economical and
efficient use. Chemical containers list the recommended
storageconditions. Meeting the recommended conditions
will increase their shelf life.
Recycle Spoiled Photographic Film and Paper.
It is a current practice in the photoprocessing and
printing industry to send used and/or spoiled film to
professional recyclers for recovery of silver (USEPA
1986). However, this option might not be practical to
small scale operations or available to facilities located
far away from recyclers.
Test Expired Materialfor Usefulness.
Materials having expired shelf-life should not
automatically be thrown out. Instead, this material
should be tested for effectiveness. The materials may be
usable, rather than becoming a waste. A recycling outlet
should be found for left over raw material that is no
longer wanted.
Extend Processing Bath Life.
Wastes from photographic processing can be reduced
by extending the life of fixing baths. Techniques include
12
(1) adding ammonium thiosulfate, which doubles the
allowable concentration of silver buildup in the bath; (2)
using an acid stop bath prior to the fixing bath; and (3)
adding acetic acid to the fixing bath as needed to keep the
pH low.
Accurately adding and monitoring chemical replenishment
of process baths will cut down chemical wastage. Stored
process bath chemicals should be protected from oxidation
by reducing exposure to air. Some smaller photo developers
store chemicals in closed plastic containers. Glass marbles
are added to bring the liquid level to the brim each time
liquid is used. In this way, the amount of chemical subject
to degradation by exposure to air is reduced, thereby
extending the chemical’s useful life and the life of the bath.
Use Squeegees.
Squeegees can be used in non-automated processing
systems to wipe excess liquid from the film and paper. This
can reduce chemical carryover from one process bath to the
next by 50 percent (Campbell and Glenn 1982). Minimizing
chemical contamination of process bath increases
recyclability, enhances the lifetime of the process baths,
and reduces the amount of replenisher chemicals required.
Most firms, however, use automated processors. Also,
using squeegees may damage the film image if it has not
fully hardened, so a squeegee should be used after the film
image has hardened.
Use Countercurrent Washing.
In photographic processors, countercurrent washing
can replace the commonly used parallel tank system. This
can reduce the amount of wastewater generated. In a
parallel system, fresh water enters each wash tank and
effluent leaves each wash tank. In countercurrent rinsing,
the water from previous rinsings is used in the initial filmwashing
stage. Fresh water enters the process only at the
final stage, at which point much of the contamination has
already been rinsed off the film. However, a countercurrent
system requires more space and equipment.
Recover Silver and Recycle Spent Chemicals.
Basically, photoprocessing chemicals consist of
developer, fixer, and rinse water, Keeping the individual
process baths as uncontaminatedas possibleis aprerequisite
to the successful recycling of these chemicals. Silver is a
component in most photographic films and paper and is
present in the wastewaters produced. Various economical
methods of recovering silver are available (e.g. metallic
replacement, chemical precipitation, electrolytic recovery),
and a number of companies market equipment that will suit
the needs of even the smallest generator.
The most common method of silver recovery employed by
hospitals is metallic replacement. The spent fixing bath is
pumped into a cartridge containing steel wool. An oxidationreduction
reaction occurs and the iron in the wool replaces
the silver in solution. The silver settles to thebottom of the
cartridge as a sludge.
Another, more efficient, method of silver recovery is
electrolytic deposition. In an electrolytic recovery unit, a
low voltage direct current is created between a carbon
anode and stainless steel cathode. Metallic silver plates
onto the cathode. Once the silver is removed, the fixing
bath may be able to be reused in the photographic
development process by mixing the desilvered solution
with fresh solution. Recovered silver is worth about 80%
of its commodity price.
Some of the companies that buy used film or cartridges
containing recovered silver can be located under “Gold and
Silver Refiners and Dealers” in a business telephone
directory. These firms may pick up directly or may purchase
through dealers. To recycle used film, it may be worth while
to sort the film into “largely black” versus “largely clear”
segments, since the rate of payment for mostly black film
may be twice that for mostly clear.
Technologies for reuse of developer and fixer are available
and include ozone oxidation, electrolysis, and ion exchange.
RADIONUCLIDES
Radioactive wastes cannot be treated or neutralized.
Therefore, sourcereduction andsubstitution are the primary
waste minimization strategies for such materials.
Knowledge of the physical and biological properties of the
various nuclides is required to enable assessment of
environmental hazards associated with waste products.
Table 2 lists properties of common nuclides used in
hospital research and treatment. The type of radiation
emitted, energy, physical and effective half lives, and
decay products are the factors which must be considered
when choosing among various nuclides. The objective is
to choose a nuclide which has a short half-life, low energy,
a stable, non-toxic decay product, and emits minimal
amounts of extraneous radiation. Extraneous radiation
refers to the production of a type of radiation which is not
required in the test or procedure. For example, if a beta
emitter is required for a certain test, a nuclide which
produces minimal gamma radiation should be chosen.
This is because gamma radiation is hazardous to the patient
and is more difficult to contain during handling.
Radium-226 is probably the most hazardous
radionuclide used in hospitals. Its physical and effective
half lives are extremely long and its decay products are
unstable. Radium-226 needles used in cancer treatment are
being phased out at many hospitals in favor of iridium- 192
or cesium- 137 needles.
13
Table 2. Properties of Radionuclides Used In Hospitals
1 Nuclide: Most common radioactive nuclides (radionuclides) present at hospitals. Tritium, iodine-125, and carbon-14 are most
commonly used at research hospitals. The “m” in barium-137m and technetium-99m represents a metastable state of that nuclide (see
note 7).
2 Type of Radiation: beta-: negative beta particle called beta minus; alpha: alpha particle; gamma: gamma ray. “no gamma” means
that nuclide emits no gammarays, which is unusual; most alpha and beta decays are accompanied by gammaradiation. Only the major
radiations are listed here.
3 Energies: Most significant energies are given here (MeV = million electron-volts). For beta-decay, a continuous spectrum of beta
energies are released up to some maximum value which is specific to a given radionuclide. The average beta- energy is a better
indication of the hazard - average beta energy is generally 30-40% of the maximum energy.
4 Physical Half-Life: The time required for half of the original number of atoms to decay: abbrev. T_ or Tp.
5 Effective Half-Life: A combination of the physical T_ (Tp) and biological T_ (Tb). where 1 = 1 + 1
Teff Tp Tb
Tb is the time required for half of the atoms to be removed from the body (through excretion)
6 R/hr per Ci at one meter: Specific activity, given for gamma-emitting radionuclides - indicates the Roentgen/hr measurement
expected from a one-Curie point source at a distance of one meter.
7 Daughters: When an atom &cays by beta or alpha emission it becomes an atom of another element; the original atom is called the
parent and the product is called the daughter. Most of the radionuclides used in hospitals have daughters that are stable (i.e., they are
notradioactive). However, some have daughters that are also radioactive, which in turn can produce subsequent radioactive daughters.
For example, as radium-226 decays, it produces seven “generations” of distinct, radioactive decay products, and only in the eighth
generation is a stable decay product, lead-206, produced. These seven daughters all emit alphas and betas and have a range of halflives.
8 N.A.: not applicable
9 Used in teletherapy units only - not routine waste.
Note: Blanks indicate no information available.
Source: Calif. DHS, 1988.
14
E. Party and E.L. Gershey of The Rockefeller
University, who reviewed the field of low-level radioactive
waste (LLRW) for the Annual Review of Public Health,
recommend several ways that the amounts of LLRW that
are generated by biomedical institutions and that require
disposal, can be reduced substantially (1989). The primary
method of waste reduction requires allocation of space
(100 to 200 square meters) on site where short-lived
radioactive materials may be isolated and stored until
decay to acceptably low levels as verified by survey meter.
They then can be disposed of as non-radioactive liquids
and trash.
Low level radioactive wastes need to be segregated
and properly labeled as to isotope, form, volume, laboratory
origin, activity, and chemical composition. Central
processing is recommended.
SOLVENTS
The primary sources of hospital solvent wastes are the
laboratory, pathology, histology, and maintenance
(engineering) ‘departments. Waste quantities vary
significantly depending on the size and specific functions
of the hospital. Solvents are used for degreasing and parts
cleaning in engineering, for fixation and preservation of
specimens in histology and pathology, and for extractions
in laboratories.
For the purposes of waste management, solvents can
be classified as either halogenated or non-halogenated.
Halogenated solvents are generally more toxic and
persistent. Specific halogenated compounds used in
hospitals include methylene chloride, chloroform,
tetrachloroethylene, chlorobenzene, trichloroethylene,
l,l,l-trichloromethane, and Freon. Non-halogenated
compounds include xylene, acetone, toluene, methanol,
ethyl ether, methyl ethyl ketone, and pyridine.
Routine procedures for managing solvent waste at
many hospitals currently include discharge to the sewer
and lab-pack disposal in landfills. While these procedures
have been considered acceptable in the past, they are no
longer advisable options and in some situations may be
illegal. Land disposal is becoming increasingly costly and
the number of substances banned from landfilling continues
to grow. Although disposal of some solvent wastes to the
sewer in small concentrations may be acceptable by some
municipal standards, state and federal laws may prohibit
such discharges. Questions of legality aside, both land
disposal and sewer discharge are environmentally unsound
alternatives.
Material Substitution
Source reduction options for solvents consist of
substituting non-halogenated compounds for halogenated
compounds, substituting simple alcohols and ketones for
petroleum hydrocarbons (i.e., toluene or xylene), and using
aqueous reagents (such as biodegradable Alconox) wherever
possible. In addition, sonic or steam cleaning can often be
substituted for alcohol-based disinfectants.
Histology solvents must dehydrate tissues, so aqueousbased
solvents are not suitable in histology. In the past,
benzene was the solvent of choice. However, due to
concerns about the hazards of benzene, it has largely been
replaced by xylene. There are a number of xylene substitutes
currently on the market, one or more of which may be a
viable substitute.
Improved Laboratory Techniques
Solvent use in laboratories has decreased in recent
years due to technological advances. For example,
monoclonal antibodies, radioisotope-labeled
immunoassays, and ultrasensitive analytical devices have
reduced or eliminated the need for solvent extractions and
fixation.
Calibrated solvent dispensers or unitized test kits
should be used. The sizes of cultures or specimens should
be minimized in the pathology, histology, and laboratory
departments.
Recycle Solvents
An important first step in determining the feasibility of
on-site distillation and recovery of waste solvents consists
of separating waste streams according to specific chemical
components. This may allow the use of simple batch
distillation equipmentwhich is less expensive than fractional
distillation equipment. Individual solvent recycling units
suitable for hospital use have been developed. One
manufacturer has a fractional distillation system equipped
with a microprocessor to automatically distill, fractionate,
and purify a solvent. It can be used, for example, to separate
xylene from ethanol in histology wastes (Roark 1989).
In the event that on-site distillation is not feasible, offsite
distillation or waste exchange should be considered.
Solvent wastes that have been kept segregated (halogenated
vs. non-halogenated) may be more easily recycled off site.
Solvent wastes with sufficiently low chlorine content can
be used as a fuel supplement in cement kilns and some
industrial boilers.
MERCURY
Electronic Sensing Devices
Perhaps the best, if not the least costly, approach to
mercury waste minimization is to eliminate mercurycontaining
instruments entirely. Substituting solid state
15
electronic sensing devices for mercury-based thermometers
and blood pressure instruments is occurring at many
hospitals. This source elimination technique appears to be
the primary reduction alternative for mercury wastes. The
higher initial costs of electronic devices are typically
justified because they eliminate costly clean-ups and
associated hazards from glass breakage and mercury spills.
Proper Spill Clean-Up
Elemental mercury exhibits high toxicity via inhalation,
skin absorption and ingestion. Spill clean-up procedures
and handling operations must be carefully designed and
monitored to protect employees and public health. Specially
designed mercury vacuums and spill absorbent kits should
be used for spill clean-ups.
Recycle/Reuse
Waste mercury can easily be recycled depending on
the type or degree of contamination. Residual mercury in
reservoirs of broken devices can be coarsely filtered and
reused. While mercury recovered from spills or otherwise
contaminated can be distilled to remove impurities, mercury
distillation requires a hazardous waste treatment permit
and possibly an air emissions permit. The equipment costs
and elaborate permitting requirements make on-site
distillation infeasible at most hospital facilities.
ECRI (ECRI March 1989) lists four mercury refineries
in the U.S:
Adrow Chemical Co.
3 Lines Ave.
Wanaque,NJ 07465
(201) 839-2372
Bethlehem Apparatus Co., Inc.
890 Front St.
Hellertown, PA 18055
(201) 838-7034
D.F. Goldsmith Chemical and Metals Corp.
909 Pitner Ave.
Evanston, IL 60202
(3 12) 869-7800
Mercury Distributors, Inc.
13814 Almeda Rd
Houston, TX 77053
(713) 433-2418
In addition, your regional U.S. Environmental Protection
Agency office or your state environmental department
may have information about commercial mercury-recovery
firms in your area.
One mercury recycler provides hospitals with an
airtight steel container that can hold up to 76 pounds of
mercury. The container is used at the hospital for
collecting and then can be used to ship the mercury to the
recycler without additional packaging (ECRI March
1989).
WASTE ANESTHETIC GASES
Non-hazardous substitutes are not available for
anesthetic gases. The waste minimization options that
are feasible are measures designed to reduce leaks and,
as a result, reduce exposure of health care personnel to
releases of these gases in the workplace. Many of these
measures are in fact ‘better operating practices.” The
reduction of in advertent releases of gases in the workplace
will, in the long run, reduce the amount of gases purchased
and the overall amount released as waste.
ECRI (Feb. 1988) recommends the following
approach for controlling waste anesthetic gases:
Use of low-leakage anesthetic equipment.
Generally equipment less than 10 years old
complies with low-leakage standards.
Proper routine maintenance, by qualified
personnel, of anesthesia equipment,
scavenging equipment, and the ventilation
system.
Daily leak testing before use of equipment.
Quarterly monitoring of waste anesthetic
levels in operating rooms, recovery rooms,
dental suites, and adjacent rooms that may
receive waste gases.
In addition, ECRI recommends several anesthetist
work practices designed to minimize leakage and resulting
worker exposure. These include, before inducing
anesthesia: confirming proper connections and leak
tightness of equipment, and avoiding spillage of liquid
anesthetics while filling vaporizers. During anesthesia
administration, anesthetists can reduce leakage by
properly fitting the mask on the patient’s face before
turning on anesthetic flow, and by turning off the gas
supply before disconnecting the breathing circuit during
short interruptions.
In larger operating rooms, the anesthesia supply
system may include permanent piping in the walls of the
room. This piping is tested rigorously for leaks at the
time of installation. However, routine post-installation
testing procedures are generally designed to assure proper
flow and pressure of the anesthetic gases without specifi-
16
tally testing for leaks. As a result, leaks in wall plumbing
may go undetected for years. To avoid losses of anesthetic
gases and exposure of hospital personnel, tests for leakage
in this part of the supply system should be performed
periodically (Bastian 1989).
TOXICS, CORROSIVES, AND MISCELLANEOUS
CHEMICALS
Standard waste minimization practices, such as
replacing oil-based paints, reducing disposal of unused or
out-of-date materials (paints, pesticides, chemicals, etc.),
controlling inventories, and improving waste tracking
systems are all applicable to the hospital environment.
Vehicle and building and grounds maintenance operations
generate waste oils, vehicle maintenance waste, solvents,
pesticides, water treatment chemicals, and possibly PCB
oil from old transformers, asbestos, and other wastes.
Opportunities to minimize wastes in these activities
include:
l Collect waste oil and solvents for recycling.
l Segregate recyclable oils and solvents from
non-recyclable wastes.
l Replace oil-based paints with water-basedpaints
in maintenance operations.
l Reduce generation of pesticide ‘waste by
reducing pesticide application, using nonchemical
pest control methods, and preparing
and using only the required quantities.
Ethylene Oxide
There are currently no acceptable non-hazardous
substitutes for ethylene oxide’s (EtO) use as a sterilant for
a number of medical devices. Several companies are
reportedly working on alternatives to ethylene oxide (EtO);
however, details on these substitutes are not yet available
(ECRI Sept. 1988).
Currently all waste Et0 is vented to the outside
atmosphere. The California Air Resources Board has
designated ethylene oxide as a toxic air contaminant; this
development may lead to emissions regulations for EtO.
Better operating practices can be employed to reduce
the chances of spillage and accidental release of Et0 in
hospitals. These include frequent inspection and proper
maintenance of Et0 sterilizerequipment including checking
the seal integrity of sterilizer doors, and proper training of
personnel in the use of Et0 sterilization equipment and
handling of Et0 cylinders and cartridges.
Use of Recyclable Drums
Many chemicals used in hospital engineering/
maintenance and in the laboratories are supplied in drums.
Unless the empty drums are triple rinsed before disposal,
they may have to be handled as hazardous waste. Many
industrial facilities now take delivery of chemicals in 400
gallon recyclable tote drums. When empty, the tote drum
is returned to the supplier for cleaning and refilling. This
will ensure that the container and any chemical residue left
inside it do not have to be disposed of by the hospital.
Proper Material Handling
Use of mechanical handling aids for drums and
adherence to general spill reduction techniques will decrease
spill potential. Pre-mixed solutions of these compounds
also decrease spill potential by reducing handling
requirements. In the laundry facility, an automated system
that pumps bleach directly from drums into the machines
decreases spillage.
Material Substitution
Oxidizers are found in hospital laundries and
laboratories. Process modification may minimize oxidizer
waste. For liquid oxidizers, such as hydrogen peroxide, the
most dilute form that will still be effective should be used.
As an example of an opportunity for process modification,
consider the procedure of using benzoyl peroxide to reduce
color in tissue or blood samples. Benzoyl peroxide is a
strong oxidizing agent that may explode spontaneously
when dry. Substituting a 30 percent hydrogen peroxide
solution for the benzoyl peroxide is more economical. This
solution is a weaker, yet effective oxidizing agent and is not
subject to spontaneous combustion.
In hospitals, poisons such as glutaral dehyde and phenol
may be used in sterile processing, laboratories, and nursing
units. The main waste minimization technique in dealing
with poisons is substitution with a less environmentally
hazardous compound or process, wherepossible. Examples
of this are steam or sonic sterilization instead of chemical
sterilization.
17
SECTION 4
GUIDELINES FOR USING THE WASTE MINIMIZATION ASSESSMENT
Waste minimization assessments were conducted at
three hospitals. The assessments were used to develop the
waste minimization questionnaire and worksheets that are
provided in this section.
A comprehensive waste minimization assessment
includes a planning and organizational step, an assessment
step that includes gathering background information and
development of waste minimization options, a feasibility
study on specific waste minimization options, and an
implementation phase.
The worksheets provided in this section are intended
to assist hospital managers in systematically evaluating
waste generating processes and in identifying waste
minimization opportunities. These worksheets includeonly
the assessment phase of the procedure described in the
Waste Minimization Opportunity Assessment Manual.
For a full description of waste minimization assessment
procedures, refer to the EPA Manual.
Table 3 lists the worksheets that are provided in this
section.
Table 3. List of Waste Minimization Assessment Worksheets
Number Title
1. Waste Generation Questionnaire
2. Waste Quantities
3. Material Procurement and Usage
4 Material Procurement and Usage
5. Waste Management Practices
6. Waste Management Practices
7A Selected Waste Streams
7B.
7C.
8A.
8B.
8C. Options/Selected Waste Streams
Selected Waste Streams
Selected Waste Streams
Options/Selected Waste Streams
Options/Selected Waste Streams
Description
Questions on hospital waste tracking
Form for documenting wastes by type and department
Questionnaire
Waste minimization options
Questionnaire
Waste minimization options
Questionnaire on chemotherapy and antineoplastics;
flammable and chlorinated solvents
Questionnaire on formaldehyde, photographic
materials, radioactive materials
Questionnaire on mercury; anesthetic gases;
and toxics, corrosives, and miscellaneous compounds
Questionnaire on general practices
Options for chemotherapy and antineoplastics;
flammable and chlorinated solvents; and formaldehyde
Options for photographic chemicals,
materials, mercury, and waste anesthetic gases
Options for toxics, corrosives and miscellaneous chemicals;
general options
18
References
American Conference of Governmental Industrial
Hygienists (ACGIH). 1987. Documentation of TLVs
and BEIs. Cincinnati, OH.
Bastian,F. 1989. Personal communication with F. Bastian,
senior industrial hygienist, ECRI, Plymouth Meeting,
PA. July 19, 1989.
Calif. DHS. August 1988. “Waste Audit Study: General
Medical and Surgical Hospitals.” Report prepared by
Ecology and Environment, Inc., San Francisco,
California, for the California Department of Health
Services, Alternative Technology Section, Toxic
Substances Control Division.
Calif. DHS. December 1988. Waste Minimization Audit
Study of the Photoprocessing Industry. Draft report
prepared for the California Department of Health
Services, Alternative Technology Section, Toxic
Substances Control Division.
Campbell, M.E. and W.M. Glenn. 1982. Profit from
Pollution Prevention: A Guide to Industrial Waste
Reduction and Recycling. Toronto, Canada: Pollution
Probe Foundation.
ECRI. January 1988. “Formaldehyde exposure: new
standard directly affects hospitals,” Hospital Hazardous
Materials Management, Vol. 1, No. 4.
ECRI. February 1988. “Waste anesthetic gases:
controlling the risk, "Hospital Hazardous Materials
Management, Vol. 1, No. 5.
ECRI. September 1988. “Et0 sterilization: possible
alternatives being developed,” Hospital Hazardous
Materials Management, Vol. 1, No. 12.
ECRI. January 1989. “Ethylene oxide: protecting your
employees,” Hospital Hazardous Materials
Management, Vol. 2, No. 4.
ECRI. March 1989. “Mercury: quicksilver and other
poisons,” Hospital Hazardous Materials
Management, Vol. 2, No.6.
Roark, R.R. June 16, 1989. Letter from R. Roark, B/R
Instrument Corp, to Andrew Nelson, Jacobs
Engineering Group Inc.
Sawyer, C.N. and P.L. McCarty 1967. Chemistry for
Sanitary Engineers. McGraw-Hill Book Co., N.Y.
The Merck Index, Tenth Ed. 1984. Rahway, N.J.
USEPA. 1988. Waste Minimization Opportunity
Assessment Manual. Hazardous Waste Engineering
Research Laboratory, Cincinnati, Ohio, EPA/625/
7-88-003.
USEPA. 1986. Waste Minimization -Issues and Options.
Volume I-III. EPA/530-SW-86-041 through-043.
U.S. Environmental Protection Agency.
Washington, D.C.
19
20
22
23
24
25
26
2 7
28
29
30
31
32
Appendix A
FACILITY ASSESSMENTS OF THREE HOSPITALS
In 1986 the California Department of Health Services some of the hazardous waste streams that the hospital
commissioned a waste minimization study (DHS 1988) of would otherwise be required to manage itself. Outthree
general medical and surgical hospitals. The objectives patient clientele consists of approximately 125 to 150
of the waste minimization assessments were to: persons per day.
l Gather site-specific information concerning the Procurement of hazardous materials is conducted
generation, handling, storage, treatment, and through a central clinic and a separate general purchasing
disposal of hazardous waste; department. Hazardous waste manifests are maintained
l Evaluate existing waste reduction practices;
by the housekeeping department. The hospital has
conducted an internal environmental compliance audit
and has inventoried hazardous materials on site. Waste
minimization, however, has not been specifically
addressed.
The laboratory and pathology departments generate
primarily xylene and formaldehyde waste, in the amount
of about one gallon each per month. In both cases, this
waste is discharged to the sewer. Reagents are used in
“contained packs” for unit applications. These are
disposed of as infectious waste.
l Develop recommendations for waste reduction
through source control, treatment, and recycling
techniques; and
l Assess costs/benefits of existing and
recommended waste reduction techniques.
In addition, the results of the waste assessments were
used to prepare waste minimization assessment worksheets
to be completed by other hospitals in a self-audit process.
The first steps in conducting the assessments were the
selection of the three hospitals, and contacting them to
solicit voluntary participation in the audit study. During
each of the hospital audits, the audit team observed a
variety of hospital operations; inspected waste management
facilities; interviewed the hospital managers, environmental
compliance personnel, and laboratory supervisors; and
reviewed and copied records pertinent to waste generation
and management. The audits were performed by one or
two engineers over a one- to three-day period depending on
the size and complexity of the formulating and waste
management operations.
This Appendix section presents the results of the
assessments of the hospitals here identified as A, B and C
and the potentially useful waste minimization options
identified through the assessments. Also included are the
practices already in use at the facilities that have successfully
reduced waste generation from past levels.
Hazardous wastes generated by the radiology/
imaging department consist of fixer, developer, and
mercury on occasion. Silver from the fixer is extracted
and 20% of the solution is recycled. Although mercury
disposal does not occur on a routine basis, it is handled
regionally.
The central sterile supply department generates
only ethylene oxide, which is vented to the atmosphere
and sewer.
The engineering department handles various
hazardous materials. It generates only about three gallons
per month of used oil, which is transported off site for
disposal. This department also uses solvents, aerosols,
and water-based latex paints, which are consumed. Boiler/
water treatment compounds are also consumed.
The pharmacy generates antineoplastic wastes,
which are hauled off site for incineration. It also generates
outdated drugs, which are returned to the regional
pharmacy (see Figure A-l).
The respiratory therapy department generates
approximately 16 ounces of 70% alcohol per day, which
is discharged to the sewer.
Findings of Waste Audit of Hospital A
Hospital A is a general surgical hospital with 323 beds
and 2,000 employees. The types of in-house departments
are typical for a full-service hospital, although much of the
laboratory work is performed through a regional laboratory
at a separate location. This regional laboratory manages
33
The hemodialysis department generates 4%
formaldehyde waste, which is disposed of to the sewer at
a rate of about 8 liters per week. It also generates 5.25%
sodium hypochlorate, which is also discharged to the
sewer, at a rate of about 10 liters per week (see Figure A-
2).
Findings of Waste Audit of Hospital B
Hospital B is a general surgical hospital with 415 beds.
In-house departments include a laboratory, pathology,
engineering, radiology, histology, dialysis, and a pharmacy.
Primary sources of hazardous wastes include hemodialysis,
the clinical testing laboratory, and the pharmacy. Outpatient
clientele consists of approximately 100 persons per day.
Hospital B has not conducted any in-house environmental
compliance or waste minimization audits.
The pharmacy purchases antineoplastic chemicals,
which are inventoried through a computerized central
receiving system. Supplies kept in-house at a given time
are inventoried to last two weeks. Antineoplastic drugs
used as chemotherapy agents are the hospital’s largest
source of hazardous waste by volume. Approximately two
five-gallon disposal cans are filled with liquid chemotherapy
waste each week. Gowns, gloves, and other
articles contaminated by cytotoxic drugs are bagged and
placed in 55-gallon steel drums. All chemotherapy
wastes are transported off-site for disposal (see Figure A-
3).
Hazardous waste generated through hemodialysis
includes 4% formaldehyde that has been pumped through
18 individual dialysis units, at the rate of 250 cc’s per day.
Effluent lines from these machines are connected to the
municipal sewer system. Tubing from the units is
discarded as infectious waste (see Figure A-4).
Radioactive tagging in the clinical testing laboratory
is also a source of hazardous waste at Hospital B.
Approximately 800 ml per week of radioactive water, or
tritium, are generated. About five gallons per month of
radioactive solid waste are also generated. Tritium is a
beta-emitter with a half-life of 57 years. An additional
200 ml per week of toluene are evaporated under a hood.
Radioactive wastes are transported off site for disposal
(see Figure A-5).
34
35
Figure A-2. Hospital A-Dialysis Waste Stream
Figure A-3. Pharmacy and Chemotherapy Waste Stream
Figure A-4. Hospital B- Dialysis Waste System
Figure A-5. Hospital B- Clinical Testing Lab (Radioactive Tagging) Waste Stream
Findings of Waste Audit of Hospital C
Hospital C is a general surgical hospital with 280
beds. The types of in-house departments are typical for a
full-service hospital, except that hemodialysis, histology
work, and certain blood tests are contracted to outside
firms. The inner-city location attracts a significant outpatient
clientele of approximately 150 to 175 persons each
weekday.
Hazardous materials are procured in two central
areas: the materials management department and the
pharmacy. The inventory system has recently been
computerized, and all chemotherapy drugs are ordered by
one pharmacist.
At Hospital C, a product evaluation committee has
been established to review product toxicity and investigate
substitution with less hazardous compounds. For example,
disinfectants containing glutaraldehyde were recently
replaced with an alcohol compound formulated in a
nonflammable water mixture.
The hospital has approached the disposal of obsolete
or expired supplies in a unique manner: materials that are
unusable are shipped to Third World countries in need of
such materials. For instance, pharmaceutical drugs that
cannot be used in the U.S. when their potency decreases
to less than 95% are usable in many other countries where
such drugs are in very scarce supply.
Hospital C has just begun to initiate its hazardous
materials right-to-know training. The sessions include
spill clean-up techniques but do not address waste
minimization or spill prevention techniques.
The hospital has not yet developed a master listing of
its hazardous waste types. These wastes are stored in the
areas where they are generated; a single person is in charge
of arranging for disposal. Small quantities of alcohols,
formaldehyde, and aromatic hydrocarbons are routinely
discharged to the sewer.
The local sanitation district prohibits discharge of
flammable petroleum solvents. However, small quantity
discharges of alcohol and formaldehyde may be permitted
if the wastes are adequately diluted.
Antineoplastic residues are the only hazardous
wastes routinely disposed of at a permitted facility. The
hospital’s chemotherapy drug handling practices result
in minimal generation of these wastes (less than 7 cubic
feet per month), which are currently landfilled. Hazardous
waste controls involving these chemical agents
include the following:
Compounding is done by a single individual
who is highly experienced.
Compounding is performed under a Type
A biological safety cabinet which draws
vapors and aerosols away from theoperator.
This reduces the potential for
contaminating protective gowns.
All antineoplastic drugs are administered
in a designated wing of the hospital. This
reduces the potential for spills and handling
of drugs by unqualified persons.
Drug containers are ordered in specified
sizes designed to reduce or eliminate
unused residues.
Spill clean-up kits are readily available in
antineoplastic drug handling areas.
The hospital has not implemented any programs
specifically designed to minimize waste. However, in
the laboratory, waste quantities have decreased in recent
years. This reduction is due to automation of equipment
and reduction in the quantity of analytes and reagents
required for analyses. The laboratory director has
obtained information on solvent distillation units.
However, the director did not purchase this equipment
due to the small quantities of solvents that the hospital
generates.
Some steps have been taken to eliminate high hazard
chemicals. For example, in recent years, the laboratory
has substituted xylene for benzene and has discontinued
the use of ether. The hospital does not dispose of
radioactive wastes. Radioisotopes are stored in a leadlined
receptacle until they disintegrate to nonhazardous
levels. These receptacles are then returned to the
manufacturer.
40
APPENDIX B
WHERE TO GET HELP
FURTHER INFORMATION ON POLLUTION PREVENTION
Additional information on source reduction, reuse and
recycling approaches to pollution prevention is available
in EPA reports listed in this section, and through state programs
(listed below) that offer technical and/or financial
assistance in the areas of pollution prevention and treatment.
In addition, waste exchanges have been established in
some areas of the U.S. to put waste generators in contact
with potential users of the waste. Four waste exchanges are
listed below. Finally, EPA’s regional offices are listed.
EPA REPORTS ON WASTE
MINIMIZATION
U.S. Environmental Protection Agency. “Waste
Minimization Audit Report: Case Studies of Corrosive
and Heavy Metal Waste Minimization Audit at a
Specialty Steel Manufacturing Complex.” Executive
Summary.*
U.S. Environmental Protection Agency. “Waste
Minimization Audit Report: Case Studies of
Minimization of Solvent Waste for Parts Cleaning and
from Electronic Capacitor Manufacturing Operation.”
Executive Summary.*
U.S. Environmental Protection Agency. “Waste
Minimization Audit Report: Case Studies of
Minimization of Cyanide Wastes from Electroplating
Operations.” Executive Summary.*
U.S. Environmental Protection Agency. Report to
Congress: Waste Minimization, Vols. I and II. EPA/
530-SW-86-033 and -034 (Washington, D.C.: U.S.
EPA, 1986).**
U.S. Environmental Protection Agency. Waste
Minimization - Issues and Options, Vols. I-III EPA/
530-SW-86-041 through -043. (Washington, D.C.:
U.S. EPA, 1986).**
* Executive Summary available from EPA,
WMDDRD, RREL, 26 West Martin Luther King Drive,
Cincinnati, OH, 45268; full report available from the
National Technical Information Service (NTIS), U.S.
Department of Commerce, Springfield, VA 22161.
** Available from the National Technical Information
Service as a five-volume set, NTIS No. PB-87-114-328.
WASTE REDUCTION TECHNICAL/
FINANCIAL ASSISTANCE PROGRAMS
The EPA’s Office of Solid Waste and Emergency Response
has set up a telephone call-in service to answer
questions regarding RCRA and Superfund (CERCLA):
(800) 242-9346 (outside the District of Columbia)
(202) 382-3000 (in the District of Columbia)
The following states have programs that offer technical
and/or financial assistance in the areas of waste minimization
and treatment.
Alabama
Hazardous Material Management and Resources Recovery
Program
University of Alabama
P.O. Box 6373
Tuscaloosa, AL 35487-6373
(205)348-8401
Alaska
Alaska Health Project
Waste Reduction Assistance Program
431 West Seventh Avenue, Suite 101
Anchorage, AK 99501
(907)276-2864
Arkansas
Arkansas Industrial Development Commission
One State Capitol Mall
Little Rock, AR 72201
(501) 371-1370
California
Alternative Technology Section
Toxic Substances Control Division
California State Department of Health Service
714/744 P Street
Sacramento, CA 94234-7320
(916) 324-1807
Connecticut
Connecticut Hazardous Waste Management Service
Suite 360
900 Asylum Avenue
Hartford, CT 06105
(203)244-2007
41
Connecticut Department of Economic Development
210 Washington Street
Hartford, CT 06106
(203) 566-7196
Georgia
Hazardous Waste Technical Assistance Program
Georgia Institute of Technology
Georgia Technical Research Institute
Environmental Health and Safety Division
O’Keefe Building, Room 027
Atlanta, GA 30332
(404) 894-3806
Environmental Protection Division
Georgia Department of Natural Resources
Floyd Towers East, Suite 1154
205 Butler Street
Atlanta, GA 30334
(404) 656-2833
Illinois
Hazardous Waste Research and Information Center
Illinois Department of Energy of Energy and Natural
Resources
1808 Woodfield Drive
Savoy, IL 61874
(217) 333-8940
Illinois Waste Elimination Research Center
Pritzker Department of Environmental Engineering
Alumni Building, Room 102
Illinois Institute of Technology
3200 South Federal Street
Chicago, IL 60616
(313) 567-3535
Indiana
Environmental Management and Education Program
Young Graduate House, Room 120
Purdue University
West Lafayette, IN 47907
(317) 494-5036
Indiana Department of Environmental Management
Office of Technical Assistance
P.O. Box 6015
105 South Meridian Street
Indianapolis, IN 46206-6015
(317) 232-8172
Iowa
Center for Industrial Research and Service
205 Engineering Annex
Iowa State University
Ames, IA 50011
(5 15) 294-3420
Iowa Department of Natural Resources
Air Quality and Solid Waste Protection Bureau
Wallace State Office Building
900 East Grand Avenue
Des Moines, IA 50319-0034
(515) 281-8690
Kansas
Bureau of Waste Management
Department of Health and Environment
Forbes Field, Building 730
Topeka, KS 66620
(913) 269-1607
Kentucky
Division of Waste Management
Natural Resources and Environmental
Protection Cabinet
18 Reilly Road
Frankfort, KY 40601
(502) 564-6716
Louisiana
Department of Environmental Quality
Office of Solid and Hazardous Waste
P.O. Box 44307
Baton Rouge, LA 70804
(504) 342-1354
Maryland
Maryland Hazardous Waste Facilities Siting Board
60 West Street, Suite 200 A
Annapolis, MD 21401
(301) 974-3432
Maryland Environmental Service
2020 Industrial Drive
Annapolis, MD 21401
(301) 269-3291
(800) 492-9188 (in Maryland)
Massachusetts
Office of Safe Waste Management
Department of Environmental Management
100 Cambridge Street, Room 1094
Boston, MA 02202
(617) 727-3260
Source Reduction Program
Massachusetts Department of Environmental Quality Engineering
1 Winter Street
Boston, MA 02108
(617) 292-5982
42
Michigan
Resource Recovery Section
Department of Natural Resources
P.O. Box 30028
Lansing, MI 48909
(517) 373-0540
Minnesota
Minnesota Pollution Control Agency
Solid and Hazardous Waste Division
520 Lafayette Road
St. Paul, MN 55155
(612) 296-6300
Minnesota Technical Assistance Program
W- 140 Boynton Health Service
University of Minnesota
Minneapolis, MN 55455
(612) 625-9677
(800) 247-0015 (in Minnesota)
Minnesota Waste Management Board
123 Thorson Center
7323 Fifty-Eighth Avenue North
Crystal, MN 55428
(612) 536-0816
Missouri
State Environmental Improvement and Energy
Resources Agency
P.O. Box 744
Jefferson City, MO 65102
(314) 751-4919
New Jersey
New Jersey Hazardous Waste Facilities Siting
Commission
Room 614
28 West State Street
Trenton, NJ 08608
(609) 292- 1459
(609) 292- 1026
Hazardous Waste Advisement Program
Bureau of Regulation and Classification
New Jersey Department of Environmental
Protection
401 East state Street
Trenton, NJ 08625
Risk Reduction Unit
Office of Science and Research
New Jersey Department of Environmental Protection
401 East state street
Trenton, NJ 08625
New York
New York State Environmental Facilities
Corporation
50 Wolf Road
Albany, NY 12205
(5 18) 457-3273
North Carolina
Pollution Prevention Pays Program
Department of Natural Resources and
Community Development
P.O. Box 27687
512 North Salisbury Street
Raleigh, NC 27611
(919) 733-7015
Governor’s Waste Management Board
325 North Salisbury Street
Raleigh, NC 27611
(919) 733-9020
Technical Assistance Unit
Solid and Hazardous Waste Management Branch
North Carolina Department of Human Resources
P.O. Box 2091
306 North Wilmington Street
Raleigh, NC 27602
(919) 733-2178
Ohio
Division of Solid and Hazardous Waste Management
Ohio Environmental Protection Agency
P.O. Box 1049
1800 WaterMark Drive
Columbus, OH 43266-1049
(614) 481-7200
Ohio Technology Transfer Organization
Suite 200
65 East State Street
Columbus, OH 43266-0330
(614) 466-4286
Oklahoma
Industrial Waste Elimination Program
Oklahoma State Department of Health
P.O. Box 53551
Oklahoma City, OK 73152
(405) 271-7353
Oregon
Oregon Hazardous Waste Reduction Program
Department of Environmental Quality
811 Southwest Sixth Avenue
Portland, OR 97204
(503) 229-5913
43
Pennsylvania
Pennsylvania Technical Assistance Program
501 F. Orvis Keller Building
University Park, PA 16802
(8 14) 865-0427
Center of Hazardous Material Research
320 William Pitt Way
Pittsburgh, PA 15238
(412) 826-5320
Bureau of Waste Management
Pennsylvania Department of
Environmental Resources
P.O. Box 2063
Fulton Building
3rd and Locust Streets
Harrisburg, PA 17120
(717) 787-6239
Rhode Island
Ocean State Cleanup and Recycling Program
Rhode Island Department of Environmental Management
9 Hayes Street
Providence, RI 02908-5003
(401) 277-3434
(800) 253-2674 (in Rhode Island)
Center for Environmental Studies
Brown University
P.O. Box 1943
135 Angell Street
Providence, RI 02912
(401) 863-3449
Tennessee
Center for Industrial Services
102 Alumni Hall
University of Tennessee
Knoxville, TN 37996
(615) 974-2456
Virginia
Office of Policy and Planning
Virginia Department of Waste Management
11th Floor, Monroe Building
101 North 14th Street
Richmond, VA 23219
(804) 225-2667
Washington
Hazardous Waste Section
Mail Stop PV-11
Washington Department of Ecology
Olympia, WA 98504-8711
(206) 459-6322
Wisconsin
Bureau of Solid Waste Management
Wisconsin Department of Natural Resources
P.O. Box 7921
101 South Webster Street
Madison, WI 53707
(608)267-3763
Wyoming
Solid Waste Management Program
Wyoming Department of Environmental Quality
Herchler Building, 4th Floor, West Wing
122 West 25th Street
Cheyenne, WY 82002
(307) 777-7752
WASTE EXCHANGES
Northeast Industrial Exchange
90 Presidential Plaza, Syracuse, NY 13202
(3 15) 422-6572
Southern Waste Information Exchange
P.O. Box 6487, Tallahassee, FL 32313
(904) 644-5516
California Waste Exchange
Department of Health Services
Toxic Substances Control Division
Alternative Technology & Policy Development Section
714 P Street
Sacramento, CA 95814
(916) 324-1807
U.S. EPA REGIONAL OFFICES
Region 1 (VT, NH, ME, MA, CT, RI)
John F. Kennedy Federal Building
Boston, MA 02203
(617) 565-3715
Region 2 (NY, NJ)
26 Federal Plaza
New York, NY 10278
(212) 264-2525
Region 3 (PA, DE, MD, WV, VA)
841 Chestnut Street
Philadelphia, PA 19107
(215) 597-9800
Region 4 (KY, TN, NC, SC, GA, FL, AL, MS)
345 Courtland Street, NE
Atlanta, GA 30365
(404) 347-4727
44
Region 5 (WI, MN, MI, IL, IN, OH)
230 South Dearborn Street
Chicago, IL 60604
(312) 353-2000
Region 6 (NM, OK, AR, LA, TX)
1445 Ross Avenue
Dallas, TX 75202
(214) 655-6444
Region 7 (NE, KS, MO, IA)
756 Minnesota Avenue
Kansas City, KS 66101
(9 13) 236-2800
Region 8 (MT, ND, SD, WY, UT, CO)
999 18th Street
Denver, CO 80202-2405
(303) 293-1603
Region 9 (CA, NV, AZ, HI)
215 Fremont Street
San Francisco, CA 94105
(415) 974-8071
Region 10 (AK, WA, OR, ID)
1200 Sixth Avenue
Seattle, WA 98101
(206) 442-5810
45 *U.S. GOVERNMENT PRINTING OFFICE: I997 - 549-001/60162
Clean Scene Services SERVING; Los Angeles, Ventura, Orange, Riverside, San Bernardino, Kern, and San Diego Counties
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We proudly service all of the following Los Angeles cities in Los Angeles County:
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Acton, Agoura Hills, ,Agua Dulce, Alhambra, Arcadia, Artesia, Avalon, Azusa, Baldwin Park, Barnes City, Belmont Heights, Bell, Bell Gardens, Bellflower, Beverly Hills, Bradbury, Burbank, Calabasas, Carson, Castaic, Canyon Country, Cerritos, Claremont, Commerce, Compton, Covina, Cudahy, Culver City, Diamond Bar, Downey, Duarte, Eagle Rock, East Los Angeles, El Monte, El Segundo, Gardena, Glendale, Glendora, Hawaiian Gardens, Hawthorne, Hermosa Beach, Hidden Hills, Hollywood, Huntington Park, Hyde Park, Industry, Inglewood, Irwindale, La Canada – Flintridge, La Habra Heights, Lakewood, La Mirada, Lancaster, La Puente, La Verne, Lawndale, Lomita, Long Beach, Los Angeles, Lynwood, Malibu, Manhattan Beach, Maywood, Monrovia, Montebello, Monterey Park, Norwalk, Palmdale, Palos Verdes Estates, Paramount, Pasadena, Pico Rivera, Pomona, Rancho Palos Valencia, Verdes, Redondo Beach, Rolling Hills, Rolling Hills Estates, Rosemead, San Dimas, San Fernando, San Gabriel, San Marino, San Pedro, Santa Clarita, Santa Fe Springs, Santa Monica, Sawtelle, Sierra Madre, Signal Hill, South El Monte, South Gate, South Pasadena, Temple City, Torrance, Tropico, Tujunga, Valencia, Vernon, Venice, Walnut, Watts, West Covina, West Hollywood, Westlake Village, Whittier and Wilmington
Also Serving Cities of Orange:
Aliso Viejo, Anaheim, Brea, Buena Park, Costa Mesa, Cypress, Dana Point, Fountain Valley, Fullerton, Garden Grove, Huntington Beach, Irvine, La Habra, La Palma, Laguna Beach, Laguna Niguel, Laguna Woods, Lake Forest, Los Alamitos, Mission Viejo, Newport Beach, Orange, Placentia, Rancho Santa Margarita, San Clemente, San Juan Capistrano, Santa Ana, Seal Beach, Stanton, Tustin, Villa Park, Westminster, Yorba Linda,
San Bernardino and Riverside County Cities:
Adelanto, Apple Valley, Barstow, Big Bear Lake, Chino, Chino Hills, Colton, Fontana, Grand Terrace, Hesperia, Highland, Loma Linda, Montclair, Needles, Ontario, Rancho Cucamonga, Redlands, Rialto, San Bernardino, Twenty-nine Palms, Upland, Victorville, Yucaipa, and Yucca Valley, Aguanga, Anza, Banning, Beaumont, Bermuda Dunes, Blythe, Cabazon, Calimesa, Canyon Lake, Cathedral City,
Cherry Valley, Chiriaco Summit, Coachella, Corona, Desert Center, Desert Hot Springs, Hemet, Homeland, Idyllwild, Indian Wells, Indio, La Quinta, Lake Elsinore, Mecca, Menifee, Mira Loma, Moreno Valley, Mountain Center, Murrieta, Norco, North Palm Springs, Nuevo, Palm Desert, Palm Springs, Perris, Pine Cove, Quail Valley, Rancho Mirage, Riverside, Romoland, Rubidoux, San Jacinto, Sky Valley, Sun City, Temecula, Thermal, Thousand Palms, Wildomar, and Winchester
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