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10/30/97 TkT 12:14 FAX 707 00331 RAY CHERNISKE t�j003 <br /> I <br /> PRE-APPLICATION QUESTIONNAIRE FOR REGISTRATION ' OR DECLARATION <br /> Does your busi or service generate any of the regulated medical waste <br /> listed below? YES 0 (circle one) <br /> If you answered this question NO, please complete the declaration <br /> statement below and return it the Department of Health Services, Medical <br /> Waste Management Program, P. O. Box 942732 , MS# 396, Sacramento, CA <br /> 94234-7320. <br /> If you answered this question YES, please fill out the registration/ <br /> Permit Application. <br /> TYPES OF REGULATED MEDICAL TASTE: <br /> (4 Laboratory waste: <br /> Specimen or microbiologic cultures, stocks of infectious agents, live <br /> and attenuated vaccines, and culture mediums <br /> (,4- Blood or body fluids: <br /> Liquid blood elements or other regulated body fluids, or articles <br /> contaminated with blood or body fluids <br /> ( ' Sharps: <br /> Such as, syringes, needles, blades, 'broken glass items, glass slides, <br /> acupuncture needles, root canal files <br /> ( } <br /> Contaminated animals: <br /> Animal carcasses, body parts, bedding. materials <br /> { } Surgical specimens:' <br /> Human or animal pairts or tissues removed surgically or by autopsy <br /> { } Isolation waste: <br /> Waste contaminated with excretion, exudate, or secretions from humans or <br /> animals who are isolated due to highly communicable diseases. <br /> NON MEDICAL WASTE GENERATOR DECLARATION: (Please Type or Print) <br /> Name: <br /> Business Address: <br /> city: State: <br /> Zip: County: <br /> Phone Number: ( } - <br /> ( ) I declare under penalty of law that I do generate medical waste. I am an <br /> employee of a facility that is already a registered medial waste <br /> generator. <br /> ( ) I declare under penalty of law that to the best of my knowledge and <br /> belief I do not generate, store, or treat any of the regulated medical <br /> wastes specified on this form. <br /> Signature: Date: <br />