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10/3tr/97 THU 12:15 FAX 707 00331 RAY CHERNISKE 11005 <br /> ...i %-I <br /> TYPES OF REGULATED MEDICAL WASTE FACILITY GENEPTES <br /> (Check those that apply) <br /> (�() Laboratory waste: <br /> Specimen or microbiologic cultures, stocks of infectious agents, live <br /> and attenuated vaccines, and culture mediums <br /> (�() Blood or body fluids.: <br /> Liquid blood elements or other regulated body fluids, or articles <br /> contaminated with blood or body fluids <br /> V�} sharps <br /> Such as, syringes,: needles, blades, broken glass items, glass slides, <br /> acupuncture needles, root canal files <br /> ( } Contaminated animals: <br /> Animal carcasses, body parts, bedding materials <br /> ( ) surgical specimens: <br /> Human or animal parts or tissues ,removed surgically or by autopsy <br /> ( } rsolation waste: <br /> Waste contaminated with excretion, exudate, or secretions from humans or <br /> animals who are isolated due to highly communicable diseases_ <br /> REOUIREt3 REGISTRATION INFORMATION: <br /> I. How many pounds of medical waste does your facility generate per month? <br /> (Tracking documents must be kept on file and are subject to audit. ) <br /> lbs <br /> 2. Place a " X " next to -the corresponding method your facility uses to <br /> dispose of medical waste. <br /> Autoclave (onsite treatment) <br /> Incinerate (onsite treatment) <br /> Microwave Technology ( onsite treatment) <br /> Authorized Medical Waste Transporter <br /> refer to g Crtof Transporter) <br /> Alternative Technology ( alternative technology list) <br /> (Name or Zreavwnt Method) <br /> (circle one) <br /> 3. Yes No Do you want to apply for a Limited Quantity Hauling Exemption? <br /> You may qualify for the exemption if you generate less than 20 <br /> pounds of medical waste per week and not more than 80 pounds <br /> per month- Refer to Section 25061 -of the California Health & <br /> Safety Code for requirements. <br /> I declare under penalty of law that to the best of my knowledge and belief <br /> the statements made herein are correct and true. I hereby consent to all <br /> necessary inspections made pursuant to the California Medical waste <br /> Management Act and incidental to the issuance of the Registration/Permit and <br /> the operation of this business. <br />