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PAYMENT <br /> .F .P ...;@v <br /> PRE-APPLICATION QUESTIONNAIRE <br /> APO 2 7 1998 <br /> REGULATED MEDICAL WASTES <br /> SAN JOAOUIN COUsVTY (check all that apply) <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Laboratory Wastes - specimen or microbiologic cultures, stocks of infectious agents, live and <br /> attenuated vaccines, and culture mediums <br /> 00 Blood or Body Fluids - liquid blood elements or other regulated body fluids, or articles <br /> contaminated with blood or body fluids <br /> Sharps - syringes, needles, blades, broken glass <br /> () Contaminated Animals - animal carcasses,body parts, bedding materials <br /> () Surgical Specimens -human or animal parts or tissues removed surgically or by autopsy <br /> () Isolation Wastes - waste contaminated with excretion, exudate, or secretions from humans or <br /> animals who are isolated due only to the highly communicable diseases listed by Centers for <br /> Disease Control as requiring Biosafety Level 4* precautions. <br /> Biosafety Level 4 viruses and diseases are: Congo-Crimean Hemorrhagic Fever,Tick-borne Encephalitis Virus Complex(Absettarov,Hanzalova,Hypr,Kumlinge,Kyasanur Forest Disease, <br /> Omsk Hemorrhagic Fever,and Russian Spring-Summer Encephalitis),Marburg Disease,Ebola,Junin Virus,Lassa Fever Virus,and Machupo Virus. <br /> 1. Does your business or service generate any of the medical wastes listed above? yes no_ <br /> If your answer is no, please complete the "Certification Statement" on Page 3 and return it with this <br /> questionnaire to the address indicated. You do not need to complete the remainder of this questionnaire. <br /> If your answer is yes, please check the types(s) of waste listed above that you or your facility generate. <br /> Please complete the rest of this questionnaire. <br /> 2. Do you generate 200 pounds or more of medical waste per month? yes-X no_ <br /> 3. Do you plan to treat your medical waste onsite (at your facility), by autoclaving, incinerating or <br /> using microwave technology? yes_no <br /> If your answers to questions 2 and 3 are no, then complete the "Certification Statement" on Page 3 and <br /> return it with this questionnaire to the address shown at the bottom of Page 1. <br /> If your answers to questions 2 or 3 are yes, complete the "Registration/Permit Application For <br /> Medical Waste" form on Page 4 and submit a "Medical Waste Management Plan01 as specified on <br /> Page 5. <br /> 4. If you generate less than 20 pounds of medical waste per week,transport less than 20 pounds <br /> at one time, and have a hauling information document on file in your office, you may apply <br /> for a Limited Quantity Hauling Exemption. This exemption allows you or your staff to transport <br /> medical waste to a medical waste treatment facility or to a consolidation point until it can be <br /> removed by a registered medical waste hauler. Do you want to apply for a Limited Quantity <br /> Hauling Exemption? yes_noy <br /> If your answer is les, a "Limited Hauling Exemption" application will be mailed to you. <br /> 2 <br />