Utah Admin. Code R315-266-502 - Hazardous Waste Pharmaceuticals - Standards for Healthcare Facilities Managing Non-Creditable Hazardous Waste Pharmaceuticals

(a) Notification and withdrawal from Sections R315-266-500 through R315-266-510 for healthcare facilities managing hazardous waste pharmaceuticals.

(1) Notification. A healthcare facility shall notify the director, using the Site Identification Form, EPA Form 8700-12, that it is a healthcare facility operating under Sections R315-266-500 through R315-266-510. A healthcare facility is not required to fill out Box 10.B., Waste Codes for Federally Regulated Hazardous Waste, of the Site Identification Form with respect to its hazardous waste pharmaceuticals. A healthcare facility shall submit a separate notification, Site Identification Form, for each site or EPA identification number.

(i) A healthcare facility that already has an EPA identification number shall notify the director, using the Site Identification Form, EPA Form 8700-12, that it is a healthcare facility as part of its next Biennial Report, if it is required to submit one, or if not required to submit a Biennial Report, within 60 days of the effective date of Sections R315-266-500 through R315-266-510, or within 60 days of becoming subject to Sections R315-266-500 through R315-266-510.

(ii) A healthcare facility that does not have an EPA identification number shall get one by notifying the director, using the Site Identification Form, EPA Form 8700-12, that it is a healthcare facility as part of its next Biennial Report, if it is required to submit one, or if not required to submit a Biennial Report, within 60 days of the effective date of Sections R315-266-500 through R315-266-510, or within 60 days of becoming subject to Sections R315-266-500 through R315-266-510.

(iii) A healthcare facility shall keep a copy of its notification on file for as long as the healthcare facility is subject to Sections R315-266-500 through R315-266-510.

(2) Withdrawal. A healthcare facility that operated under Sections R315-266-500 through R315-266-510 but is no longer subject to Sections R315-266-500 through R315-266-510, because it is a very small quantity generator under Section R315-262-14, and elects to withdraw from Sections R315-266-500 through R315-266-510, shall notify the director using the Site Identification Form, EPA Form 8700-12, that it is no longer operating under Sections R315-266-500 through R315-266-510. A healthcare facility is not required to fill out Box 10.B., Waste Codes for Federally Regulated Hazardous Waste, of the Site Identification Form with respect to its hazardous waste pharmaceuticals. A healthcare facility shall submit a separate notification, Site Identification Form, for each EPA identification number.

(i) A healthcare facility shall submit the Site Identification Form notifying that it is withdrawing from Sections R315-266-500 through R315-266-510 before it begins operating under the conditional exemption of Section R315-262-14.

(ii) A healthcare facility shall keep a copy of its withdrawal on file for three years from the date of signature on the notification of its withdrawal.

(b) Training of personnel managing non-creditable hazardous waste pharmaceuticals at healthcare facilities. A healthcare facility shall ensure that any personnel that manage non-creditable hazardous waste pharmaceuticals are thoroughly familiar with proper waste handling and emergency procedures relevant to their responsibilities during normal facility operations and emergencies.

(c) Hazardous waste determination for non-creditable pharmaceuticals. A healthcare facility that generates a solid waste that is a non-creditable pharmaceutical shall determine whether that pharmaceutical is a hazardous waste pharmaceutical, for example, it exhibits a characteristic identified in Sections R315-261-20 through R315-261-24 or is listed in Sections R315-261-30 through R315-261-35, to determine whether the waste is subject to Sections R315-266-500 through R315-266-510. A healthcare facility may choose to manage its non-hazardous waste pharmaceuticals as non-creditable hazardous waste pharmaceuticals under Sections R315-266-500 through R315-266-510.

(d) Standards for containers used to accumulate non-creditable hazardous waste pharmaceuticals at healthcare facilities.

(1) A healthcare facility shall place non-creditable hazardous waste pharmaceuticals in a container that is structurally sound, compatible with its contents, and that lacks evidence of leakage, spillage, or damage that could cause leakage under reasonably foreseeable conditions.

(2) A healthcare facility that manages ignitable or reactive non-creditable hazardous waste pharmaceuticals, or that mixes or commingles incompatible non-creditable hazardous waste pharmaceuticals shall manage the container so that it does not have the potential to:

(i) generate extreme heat or pressure, fire or explosion, or violent reaction;

(ii) produce uncontrolled toxic mists, fumes, dusts, or gases in sufficient quantities to threaten human health;

(iii) produce uncontrolled flammable fumes or gases in sufficient quantities to pose a risk of fire or explosions;

(iv) damage the structural integrity of the container of non-creditable hazardous waste pharmaceuticals; or

(v) through other like means threaten human health or the environment.

(3) A healthcare facility shall keep containers of non-creditable hazardous waste pharmaceuticals closed and secured in a manner that prevents unauthorized access to its contents.

(4) A healthcare facility may accumulate non-creditable hazardous waste pharmaceuticals and non-hazardous non-creditable waste pharmaceuticals in a container together, except that non-creditable hazardous waste pharmaceuticals prohibited from being combusted because of the dilution prohibition of Subsection R315-268-3(c), that is, metal-bearing waste codes listed in Section R315-268-57, unless one or more criteria in Subsections R315-268-3(c)(1) through R315-268-3(c)(6) are met, or because it is prohibited from being lab packed due to Subsection R315-268-42(c), that is, waste codes listed in Section R315-268-53, shall be accumulated in separate containers and labeled with the applicable EPA hazardous waste numbers, in other words the hazardous waste codes.

(e) Labeling containers used to accumulate non-creditable hazardous waste pharmaceuticals at healthcare facilities. A healthcare facility shall label or clearly mark each container of non-creditable hazardous waste pharmaceuticals with the phrase "Hazardous Waste Pharmaceuticals".

(f) Maximum accumulation time for non-creditable hazardous waste pharmaceuticals at healthcare facilities.

(1) A healthcare facility may accumulate non-creditable hazardous waste pharmaceuticals on-site for one year or less without a permit or having interim status.

(2) A healthcare facility that accumulates non-creditable hazardous waste pharmaceuticals on-site shall demonstrate the length of time that the non-creditable hazardous waste pharmaceuticals have been accumulating, starting from the date it first becomes a waste. A healthcare facility may make this demonstration by any of the following methods:

(i) marking or labeling the container of non-creditable hazardous waste pharmaceuticals with the date that the non-creditable hazardous waste pharmaceuticals became a waste;

(ii) maintaining an inventory system that identifies the date the non-creditable hazardous waste pharmaceuticals being accumulated first became a waste; or

(iii) placing the non-creditable hazardous waste pharmaceuticals in a specific area and identifying the earliest date that any of the non-creditable hazardous waste pharmaceuticals in the area became a waste.

(g) Land disposal restrictions for non-creditable hazardous waste pharmaceuticals. The non-creditable hazardous waste pharmaceuticals generated by a healthcare facility are subject to the land disposal restrictions of Rule R315-268. A healthcare facility that generates non-creditable hazardous waste pharmaceuticals shall comply with the land disposal restrictions in accordance with Subsection R315-268-7(a) requirements, except that it is not required to identify the hazardous waste numbers, in other words the hazardous waste codes, on the land disposal restrictions notification.

(h) Procedures for healthcare facilities for managing rejected shipments of non-creditable hazardous waste pharmaceuticals. A healthcare facility that sends a shipment of non-creditable hazardous waste pharmaceuticals to a designated facility with the understanding that the designated facility can accept and manage the waste, and later receives that shipment back as a rejected load in accordance with the manifest discrepancy requirements of Section R315-264-72 or R315-265-72 may accumulate the rejected non-creditable hazardous waste pharmaceuticals on-site for up to an additional 90 calendar days provided the rejected shipment is managed in accordance with Subsections R315-266-502(d) and R315-266-502(e). Upon receipt of the rejected shipment, the healthcare facility shall:

(1) sign either:

(i) item 18c of the original manifest, if the original manifest was used for the returned shipment; or

(ii) item 20 of the new manifest, if a new manifest was used for the returned shipment;

(2) provide the transporter a copy of the manifest;

(3) within 30 calendar days of receipt of the rejected shipment, send a copy of the manifest to the designated facility that returned the shipment to the healthcare facility; and

(4) within 90 calendar days of receipt of the rejected shipment, transport or offer for transport the returned shipment in accordance with the shipping standards of Subsection R315-266-508(a).

(i) Reporting by healthcare facilities for non-creditable hazardous waste pharmaceuticals.

(1) Biennial reporting by healthcare facilities. Healthcare facilities are not subject to biennial reporting requirements under Section R315-262-41, with respect to non-creditable hazardous waste pharmaceuticals managed under Sections R315-266-500 through R315-266-510.

(2) Exception reporting by healthcare facilities for a missing copy of the manifest.

(i) For shipments from a healthcare facility to a designated facility:

(A) If a healthcare facility does not receive a copy of the manifest with the signature of the owner or operator of the designated facility within 60 calendar days of the date the non-creditable hazardous waste pharmaceuticals were accepted by the initial transporter, the healthcare facility shall submit:

(I) a legible copy of the original manifest, indicating that the healthcare facility has not received confirmation of delivery, to the director; and

(II) a handwritten or typed note on the manifest itself, or on an attached sheet of paper, stating that the return copy was not received and explaining the efforts taken to locate the non-creditable hazardous waste pharmaceuticals and the results of those efforts.

(B) Reserved.

(ii) For shipments rejected by the designated facility and shipped to an alternate facility:

(A) If a healthcare facility does not receive a copy of the manifest for a rejected shipment of the non-creditable hazardous waste pharmaceuticals that is forwarded by the designated facility to an alternate facility, using appropriate manifest procedures, with the signature of the owner or operator of the alternate facility, within 60 calendar days of the date the non-creditable hazardous waste was accepted by the initial transporter forwarding the shipment of non-creditable hazardous waste pharmaceuticals from the designated facility to the alternate facility, the healthcare facility shall submit:

(I) a legible copy of the original manifest, indicating that the healthcare facility has not received confirmation of delivery, to the director; and

(II) a handwritten or typed note on the manifest itself, or on an attached sheet of paper, stating that the return copy was not received and explaining the efforts taken to locate the non-creditable hazardous waste pharmaceuticals and the results of those efforts.

(B) Reserved.

(3) Additional reports. The director may require healthcare facilities to furnish additional reports concerning the quantities and disposition of non-creditable hazardous waste pharmaceuticals.

(j) Recordkeeping by healthcare facilities for non-creditable hazardous waste pharmaceuticals.

(1) A healthcare facility shall keep a copy of each manifest signed in accordance with Subsection R315-262-23(a) for three years or until it receives a signed copy from the designated facility that received the non-creditable hazardous waste pharmaceuticals. This signed copy shall be kept as a record for at least three years from the date the waste was accepted by the initial transporter.

(2) A healthcare facility shall keep a copy of each exception report for a period of at least three years from the date of the report.

(3) A healthcare facility shall keep records of any test results, waste analyses, or other determinations made to support its hazardous waste determinations consistent with Subsection R315-262-11(f), for at least three years from the date the waste was last sent to on-site or off-site treatment, storage or disposal. A healthcare facility that manages its non-creditable non-hazardous waste pharmaceuticals as non-creditable hazardous waste pharmaceuticals is not required to keep documentation of hazardous waste determinations.

(4) The periods of retention referred to in Section R315-266-502 are extended automatically during any unresolved enforcement action regarding the regulated activity, or as requested by the director.

(5) Records shall be readily available upon request by an inspector.

(k) Response to spills of non-creditable hazardous waste pharmaceuticals at healthcare facilities. A healthcare facility shall immediately contain any spills of non-creditable hazardous waste pharmaceuticals and manage the spill clean-up materials as non-creditable hazardous waste pharmaceuticals in accordance with the requirements of Sections R315-266-500 through R315-266-510.

(l) Accepting non-creditable hazardous waste pharmaceuticals from an off-site healthcare facility that is a very small quantity generator. A healthcare facility may accept non-creditable hazardous waste pharmaceuticals from an off-site healthcare facility that is a very small quantity generator under Section R315-262-14, without a permit or without having interim status, provided the receiving healthcare facility:

(1) is under the control of the person, as defined in Section R315-260-10, that controls the very small quantity generator healthcare facility that is sending the non-creditable hazardous waste pharmaceuticals off-site, "control," for the purposes of Section R315-266-502, means the power to direct the policies of the healthcare facility, whether by the ownership of stock, voting rights, or otherwise, except that contractors who operate healthcare facilities on behalf of a different person as defined in Section R315-260-10 may not be considered to "control" the healthcare facilities, or has a contractual or other documented business relationship whereby the receiving healthcare facility supplies pharmaceuticals to the very small quantity generator healthcare facility;

(2) is operating under Sections R315-266-500 through R315-266-510 for the management of its non-creditable hazardous waste pharmaceuticals;

(3) manages the non-creditable hazardous waste pharmaceuticals that it receives from off site in compliance with Sections R315-266-500 through R315-266-510; and

(4) keeps records of the non-creditable hazardous waste pharmaceuticals shipments it receives from off site for three years from the date that the shipment is received.

Notes

Utah Admin. Code R315-266-502

Adopted by Utah State Bulletin Number 2020-19, effective 9/14/2020 Amended by Utah State Bulletin Number 2025-02, effective 1/13/2025