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Docusign Envelope lD: 926EC61 6-7738-4C44-A27D-F89775E931 FA <br />Customer ID #:Site ID #:_ <br />{+Stgficycle' 'Washington, Oregon, Idaho and Alaska Rider <br />Mntct'inl Cods Chectr if dispensed <br />Warfarin >0,370 P00l <br />Epinepluine P042 <br />Plryeotigmine <br />Salicylnfo <br />P188 <br />Physqtigndne p204 <br />Mitomycin u010 <br />Acetnl4ehyde, <br />trichloro <br />u034 <br />Cyclophosphnmide u058 <br />I)aunornyoin u059 <br />Cycloloxnne ut29 <br />Melphalau ul50 <br />a <br />I unclerctand that RCRA hazardous wastc can not be accepted as medical waste by Stericycle and may not be placed in sharps <br />coltainers or in medical waste containers (i,e, r'ec1 bags) at site location(s) listed or agreement, I acknowledge that the foliowing <br />ilformatiol is accurate ancl complete regarding RCRA hazardous waste and I have presented this information to the necessary <br />ildividgals on the staff. In addition, in Washington state only dangerons waste may not be disposed of in regulated medical waste <br />containers. Please refer to the Stericycle Waste Acceptance Protocol to know what is acceptable for RMW containers' <br />RCRA hazardols waste generated by the healthcare industry commonly inclndes, but is not limited to, the medications listed <br />below. For medications with a o'P" code on the table below, empty syringes, ampules, or other containers are considered RCRA <br />waste. For medications with a "U" code on the table below, empty (less than 3% by volume) sylingos, ampules, or other containers <br />are not considered RCRAwaste. <br />Please checft only the statements that are applicable to the location(s) in agreement llsted above: <br />tr No RCRA hazardous wastes are generated. <br />tr This facility disponses the following <br />medications that, when disposed of, <br />may be considered RCRA waste <br />(check all applicable medications): <br />{ XRCRA hazardous wastes genorated at this tocation(s) are properly segregated and disposed of <br />with a licensed waste recycling or disposal service and not included in the medical waste stream. <br />Print Name:Date:ta <br />Facility Name:Kittitas County - Jail <br />Code CASRN IIse Tr.rrde Nnrne(s) <br />P00l il-81-2 Cournadin. Jnnloven <br />Epinephrine PA42 st-43.4 Ernergency allergy klts, cettain types of glaucoma, eye <br />surserv. cardiac rnrest <br />epipen, dpirrpluine <br />Physotlgrnine Salicylate Pl88 s7-64-7 Achollnergenics (liber$tes/acts like ncetylchollne)Eserine, Physostlgntine <br />Physotlglrire P204 5747-6 Acholinergenics (liberates/acts like acetlcholiue)Eserl@ostigmlne <br />Mltomvcln u0t0 1404-00-8 Chenrotherapv Mltomvcln. Mutarnvsln. Mitosol <br />Acetaldehvde. trichloro u034 302-17-0 Sedntive Chlornl Hvdrate. Sonutote. Chloralum, Aquachloral <br />Cvclophosphamide u058 6055-19.2 Chcrnotherapy Cvtox0n. Neosaf . Cvclophospharnlde <br />Daunomvcin u059 20830-81-3 Chernotherauv Cenrbldirre. Dnunorubicin HCL, Daunoxome <br />Cvclohexane ut29 110-82.4 Scabios Lindane. Kwell <br />Melnhnlur u150 148-82-3 CheDrothernov Alkernn. Melphnlnn <br />Signature:Title;3),ra"l$ <br />Phone Number: (_Email: <br />Commonts: <br />Steileycle respects your prlvacy and vttll not dtstrlbute your personal lntonnatlon wlthout permlsslon.