EOEEA-DEP – Department of Environmental Protection

Applicant Information

Name of sponsoring organization(Required)

Sponsor contact person(Required)

First Last

Sponsor contact title(Required)

Sponsor contact phone(Required)

Sponsor contact email(Required)

Mailing address(Required)

Street Address Address Line 2 City State ZIP Code

Application type(Required)

Organization collecting waste medications from residents

Installation of a permanent waste medication collection kiosk at a pharmacy or long-term care facility

Permanent residential waste medication collection kiosk at a police station

Residential Waste Medications Collection Event Information

Instructions & Notes:

Provide contact information for the person who will be responsible for on-site supervision of the collection, packaging & disposal of waste medications.
No other household hazardous wastes - such as waste oil, oil-based paints, paint thinner, mercury products, etc. - are covered by this waiver.
Medications discarded by businesses cannot be accepted under the terms of this waiver, and must be managed in compliance with the Massachusetts Hazardous Waste Regulation (310 CMR 30.000).
The local police department or other law enforcement staff must have sole possession of all controlled substances collected, and must witness their destruction at the disposal facility.
MassDEP recommends storing waste medications in five-gallon plastic pails that are structurally sound, have secure lids, and are compatible with the waste medications collected. The DEA requires that these containers be placed in a secure cabinet or locker after the collection event and until they are transported to a disposal facility.

Event

Building or facility where the waste medications will be collected	Building or facility street address	Time and date of event	Actions

There are no Events.

On-site supervisor name and contact information

Is the on-site supervisor the same as the sponsor information listed in the Application Information section above?(Required)

Yes, same as above

No, I will complete below

On-site supervisor name(Required)

First Last

On-site supervisor title(Required)

On-site supervisor mobile phone(Required)

On-site supervisor office phone(Required)

On-site supervisor email(Required)

Waste materials to be collected at this event: discarded medications only

Waste materials to be collected from: private residents only

Note: Waste medications from businesses must be managed in full compliance with 310 CMR 30.000.

Disposal facility where waste medications will be delivered(Required)

Facility address(Required)

Street Address Address Line 2 City State ZIP Code

Anticipated date of collected waste medication delivery to this facility for destruction/disposal(Required)

Law enforcement agency that will have custody of waste medications(Required)

Law enforcement staff person reponsible, name and contact information

Is the law enforcement staff person reponsible the same as the sponsor information listed in the Application Information section above?(Required)

Yes, same as above

No, I will complete below

Law enforcement staff person responsible(Required)

First Last

Law enforcement staff person phone(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Type of containers in which collected waste medications will be stored(Required)

Description of containers

Description of secure storage location where containers of collected waste medications will be kept:(Required)

Description of secure storage location

Kiosk, Security & Disposal Information - Pharmacy or Long-Term Care Facility

Instructions & Notes:

Provide contact information for the person responsible for on-site supervision of the collection, packaging & disposal of waste medications.
No other household hazardous wastes – e.g., waste oil, oil-based paints, paint thinner, mercury products, etc. - are covered by this waiver.
Medications discarded by businesses may not be accepted under this waiver & must be managed in compliance with the Massachusetts Hazardous Waste Regulation (310 CMR 30.000).

Building or facility where the kiosk will be located(Required)

Days and hours of operation(Required)

e.g. Monday - Saturday, 9:00 AM - 2:00 PM

Facility or kiosk address(Required)

Street Address Address Line 2 City State ZIP Code

On-site supervisor name and contact information

Is the on-site supervisor the same as the sponsor information listed in the Application Information section above?(Required)

Yes, same as above

No, I will complete below

On-site supervisor name(Required)

First Last

On-site supervisor title(Required)

On-site supervisor mobile phone(Required)

On-site supervisor office phone(Required)

On-site supervisor email(Required)

Pharmacy (authorized collector) DEA registration number(Required)

Waste materials to be collected at this kiosk: discarded medications only

Waste materials to be collected from: private residents only

Permitted solid waste disposal facility where waste medications will be delivered for disposal(Required)

Facility address(Required)

Street Address Address Line 2 City State ZIP Code

DEA registrant in custody of waste medications(Required)

Name

DEA registrant staff person responsible(Required)

First Last

DEA registrant staff person phone(Required)

DEA registrant staff person email(Required)

DEA registrant staff person address(Required)

Street Address Address Line 2 City State ZIP Code

Description of containers in which collected waste medications will be stored(Required)

Description of secure storage location(Required)

Kiosk Requirements - Pharmacy or Long-Term Care Facility

All collected household hazardous waste pharmaceuticals shall be placed into a kiosk that shall be a heavy metal container, with a top one-way opening drop slot and a lock, operated pursuant to 21 CFR 1317.75.
The kiosk shall be located inside a retail pharmacy, or a hospital/clinic with an on-site pharmacy, or long-term care facility (LTCF) that is registered with DEA to collect waste medications from residents pursuant to 21 CFR 1317.40 or 21 CFR 1317.80.
A copy of the DEA collector registration for the pharmacy kiosk shall be included with this application.
The kiosk shall be mounted to the ground or a wall, and under video surveillance or in an area regularly monitored by pharmacy/hospital/clinical staff, while the retail or hospital pharmacy is open to the public or the LTCF is operational.
Signs and/or messaging shall be posted at the kiosk instructing residents to drop off waste medications only; the sign shall also clearly state that residents may not place prohibited items, such as sharps, thermometers and other non-pharmaceutical wastes, into the kiosk.
Access to kiosk contents shall be limited to pharmacy/hospital/clinical/facility staff who are subject to and follow the DEA regulations at 21 CFR 1317.60(b) and (c), 1317.75(f)-(g), and 1317.80(c), and who shall have sole access to the key for the kiosk.
Only residential consumers may drop off waste medications at pharmacies; businesses are prohibited from doing so.
LTCFs may dispose of Schedule II, III, IV & V controlled substances on behalf of current and former residents per 21 CFR 1317.80(a).
The container in the kiosk shall be removed and sealed immediately after it becomes full (21 CFR 1317.60(a)(2)).
Waste medications shall be disposed within 180 days of the date on which they are removed from the kiosk.
Waste medications shall be disposed of in the presence of staff from an organization registered as a waste medication collector with DEA at the solid waste disposal facility referenced in your application.
Waste medications shall otherwise be processed and disposed of in accordance with DEA’s policies and procedures for drug destruction as defined in 21 CFR 1317.

Kiosk, Security & Disposal Information - Police Station

Instructions & Notes:

Provide contact information for the person responsible for on-site supervision of the collection, packaging & disposal of waste medications.
No other household hazardous wastes – e.g., waste oil, oil-based paints, paint thinner, mercury products, etc. - are covered by this waiver.
Medications discarded by businesses may not be accepted under this waiver & must be managed in compliance with the Massachusetts Hazardous Waste Regulation (310 CMR 30.000).

Building or facility where the kiosk will be located(Required)

Days and hours of operation(Required)

e.g. Monday - Saturday, 9:00 AM - 2:00 PM

Building or facility address

Is the building or facility address the same as sponsor contact mailing address listed in the Application Information section above?(Required)

Yes, same as above

No, I will complete below

Building or facility address(Required)

Street Address Address Line 2 City State ZIP Code

On-site supervisor name and contact information

Is the on-site supervisor the same as the sponsor contact information listed in the Application Information section above?(Required)

Yes, same as above

No, I will complete below

On-site supervisor name(Required)

First Last

On-site supervisor title(Required)

On-site supervisor mobile phone(Required)

On-site supervisor office phone(Required)

On-site supervisor email(Required)

Waste materials to be collected at this kiosk: discarded medications only

Waste materials to be collected from: private residents only

Permitted solid waste disposal facility where waste medications will be delivered for disposal(Required)

Facility address(Required)

Street Address Address Line 2 City State ZIP Code

Law enforcement agency contact person information

Is the law enforcement agency contact person the same as the sponsor contact information listed in the Application Information section above?(Required)

Yes, same as above

No, I will complete below

Law enforcement agency in custody of waste medications(Required)

Name

Law enforcement staff person responsible(Required)

First Last

Law enforcement staff person phone(Required)

Law enforcement staff person email(Required)

Law enforcement staff person address(Required)

Street Address Address Line 2 City State ZIP Code

Description of containers in which collected waste medications will be stored(Required)

Description of secure storage location(Required)

Kiosk Requirements - Police Station

All collected household hazardous waste pharmaceuticals shall be placed into a kiosk that shall be a heavy metal container, the approximate size of a mailbox, with a top one-way opening drop slot, and a lock.
The kiosk shall be located inside or in the vestibule of a police station, mounted to the ground or wall, and under 24-hour direct or video surveillance.
Signs shall be posted at the kiosk instructing residents to drop off waste medications only; the sign shall also clearly state that residents cannot place prohibited items, such as sharps, thermometers and other non-pharmaceutical wastes, into the kiosk.
Access to kiosk contents shall be limited to a police officer who shall have sole access to the key for the kiosk.
Only residents can drop off waste medications; businesses are prohibited from dropping off waste medications.
The container in the kiosk shall be emptied immediately after it becomes full.
Waste medications removed from the kiosk shall be moved directly to the Police Department’s evidence room, where they will be kept while awaiting disposal.
Waste medications shall be disposed within 180 days of the date on which they are removed from the kiosk.
Waste medications shall be disposed of in the presence of a police officer at the solid disposal facility referenced in this application.
Waste medications shall otherwise be disposed of in accordance with the policies and procedures described in the police department’s program for drug destruction.

Certification Statement

“I attest under the pains and penalties of perjury that:

The residential waste medication collection event and subsequent storage and transportation of collected medications to a permitted Massachusetts solid waste facility for destruction/disposal will be conducted in accordance with the requirements established by the U.S. Drug Enforcement Administration and the Massachusetts Department of Public Health; and
I am fully authorized to make this attestation on behalf of this organization. I am aware that there are significant penalties, including but not limited to possible fines, for submitting false, inaccurate, or incomplete information.”

“I attest under the pains and penalties of perjury that:

Residential waste medication collection and subsequent storage and transportation of collected medications to a permitted or approved solid waste facility in Massachusetts or another state for destruction/disposal will be conducted per all federal drug enforcement, environmental, and transportation regulatory requirements that apply.
Failure to comply with the foregoing conditions and statements will result in immediate revocation of this waiver approval, requiring this organization to manage any hazardous pharmaceuticals it collects as hazardous wastes under 310 CMR 30.000, and may result in enforcement action pursuant to M.G.L. Chapter 21C and 310 CMR 30.000.
I am fully authorized to make this attestation on behalf of this organization. I am aware that there are significant penalties, including but not limited to possible fines, for submitting false, inaccurate, or incomplete information.”

“I attest under the pains and penalties of perjury that:

Residential waste medication collection and subsequent storage and transportation of collected medications to a permitted or approved solid waste facility in Massachusetts or another state for destruction/disposal will be conducted per all federal drug enforcement, environmental, and transportation regulatory requirements that apply.
Failure to comply with the foregoing conditions and statements will result in immediate revocation of this waiver approval, requiring this organization to manage any hazardous pharmaceuticals it collects as hazardous wastes under 310 CMR 30.000, and may result in enforcement action pursuant to M.G.L. Chapter 21C and 310 CMR 30.000.
I am fully authorized to make this attestation on behalf of this organization. I am aware that there are significant penalties, including but not limited to possible fines, for submitting false, inaccurate, or incomplete information.”

Print Name(Required)

First Last

Title or position(Required)

Date(Required)