Form DTSC1375 "Hospital System Partnership Sign up Form" - California

What Is Form DTSC1375?

This is a legal form that was released by the California Department of Toxic Substances Control - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 5, 2005;
  • The latest edition provided by the California Department of Toxic Substances Control;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form DTSC1375 by clicking the link below or browse more documents and templates provided by the California Department of Toxic Substances Control.

ADVERTISEMENT
ADVERTISEMENT

Download Form DTSC1375 "Hospital System Partnership Sign up Form" - California

942 times
Rate
(4.4 / 5) 57 votes
State of California – California Environmental Protection Agency
Department of Toxic Substances Control
Hospital System Partnership Sign Up Form
California Mercury (Hg) Elimination Leadership Program (HELP)
Please check the appropriate responses, provide any relevant information and return this form to the Department of Toxic
Substances Control, Office of Pollution Prevention and Technology Development, P2CU – HELP Awards, P.O. Box 806,
Sacramento, California, 95812-0806.
Date:
Hospital System Name:
Street Address:
Mailing Address (if different from Street Address):
City:
Zip Code:
Attach a listing of the hospitals in your system, or write in the hospital name and location.
Ongoing HELP Contact Name:
Contact Title:
Contact Telephone:
Contact E-mail address:
DTSC may post our hospital system members on their website as working towards the goal of mercury-free.
Once a hospital becomes mercury-free, DTSC may post names photos of our award recipients on their website.
Our Hospital System is interested in a two hour training session on mercury reduction for our members.
Send our member hospitals the CD with mercury verification and elimination tools.
I would like our Publicly Owned Treatment Works (POTW) to help with local involvement.
Sign our system hospitals up as partners with Hospitals for a Healthy Environment (H2E). Once a hospital receives
recognition by the State of California for mercury elimination, they will also receive the Making Medicine Mercury-Free
Award from H2E. For more information, see H2E’s website and Partner Registration Pledge Form at
<http://www.h2e-online.org/about/index.htm>.
DTSC 1375 (12/05/03)
State of California – California Environmental Protection Agency
Department of Toxic Substances Control
Hospital System Partnership Sign Up Form
California Mercury (Hg) Elimination Leadership Program (HELP)
Please check the appropriate responses, provide any relevant information and return this form to the Department of Toxic
Substances Control, Office of Pollution Prevention and Technology Development, P2CU – HELP Awards, P.O. Box 806,
Sacramento, California, 95812-0806.
Date:
Hospital System Name:
Street Address:
Mailing Address (if different from Street Address):
City:
Zip Code:
Attach a listing of the hospitals in your system, or write in the hospital name and location.
Ongoing HELP Contact Name:
Contact Title:
Contact Telephone:
Contact E-mail address:
DTSC may post our hospital system members on their website as working towards the goal of mercury-free.
Once a hospital becomes mercury-free, DTSC may post names photos of our award recipients on their website.
Our Hospital System is interested in a two hour training session on mercury reduction for our members.
Send our member hospitals the CD with mercury verification and elimination tools.
I would like our Publicly Owned Treatment Works (POTW) to help with local involvement.
Sign our system hospitals up as partners with Hospitals for a Healthy Environment (H2E). Once a hospital receives
recognition by the State of California for mercury elimination, they will also receive the Making Medicine Mercury-Free
Award from H2E. For more information, see H2E’s website and Partner Registration Pledge Form at
<http://www.h2e-online.org/about/index.htm>.
DTSC 1375 (12/05/03)