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Lodi Memorial East 40 <br />11 <br />PIT,—APP11CATION QUESM(WINALTRE <br />Please check the appropriate response for the questions listed below. <br />RE,C]UL,k-n-T-) MFDICAT- WASITS <br />X Labc�ratozry Wastes - specimen or microbiologic cull',-ures, stocks of inifectious agents, <br />live art attenuated vaccines, and culture rnediums <br />X Bloc -A or Body Fluids - liquid blood elements or other reguhated body fluids, or <br />att`�]c.'-s containinated with blood or body fluids <br />N sh'a-mis - syri*nges, needl(cs, blades, broken glass <br />Contarninated ArdniaLs - animal carcasses, body parts, bedding materials <br />Suxyical Spc:cirnc-ms - human or aninial parts or tissues relmoved surgically or by <br />'utopsy <br />lsolation'Wastes ® waste contarrvinated with excretion, exudate, or secretions from <br />I io highly coriun-ur-dcable diseases <br />humans or animals wl are isolated due only to thl-- 0 <br />listed by Centeis for Disease Control as requiring Biosafety Level 4 precautions.* <br />1. Does your business or service generate any of <br />the mediail wastes listed above? yea= )b10 -- <br />if your answer is no, piease complete the "CCr-tjfj*cjtjo�j SLatement" on Page <br />5 and retuirn it withthisqu-stionnaire to the address indicated. You do not <br />need to complete the remainder of this questionnaire. <br />19 <br />J, your cmswer is M- please check the types(s) of waste listecl abavc ghat <br />vou or your facility gellerat-1. Please complete the rest of this questiolulaire. <br />2, Do you generate less than 200 potinds of'medical <br />waste her month? if yes, you are a small <br />gerierator. yes—noy <br />3. Small generators may store their medical waste <br />in a pen -rutted conavion storage fcilityvvitli <br />other say,,all genexators. Do you plan to do this <br />at your facfftv? yes__no Y <br />en-ni t <br />If your answer is 3E-� r,,HD Tcori, Stcragc F.a d ty P <br />a PHS - <br />wl' 11 be In,,ifled to you. Please indicate if you want the <br />am)lllcation� mailed cels ewhere. <br />-CON-11NUFLI) ON <br />10 <br />