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Jan. 24. 2019 11 : 34AM SUTTER TRACY HOSPITAL No. 8271 P. 2/6 <br /> SAN 10 A g U I N Environmental Health Department <br /> COU N1-Y <br /> PRE-APPLICATION QUESTIONNAIRE <br /> Regulated Medlcal Wastes <br /> Please check the appropriate box for the questions listed below: <br /> �Q Pharmaceuticals;prescription or over-the-counter human or veterinary drug,including, but not limited to,a drug as <br /> defined in Section 108825 of the Federal Food,Drug, and Cosmetic Act, as amended [21 U.S.C.A. Sec. 321(g)(1)]. <br /> This definition does not Include RCRA waste, l <br /> \® Laboratory Wastes: specimen or microbiologic cultures,stocks of Infectious agents, live and attenuated vaccines <br /> and Culture mediums. <br /> Blood or Body Fluids; liquid blood elements, other regulated body fluids, articles contaminated with blood or body <br /> fluids. <br /> Sharps:syringes,needles, blades and contaminated broken glass. <br /> ❑ Contaminated Animals: animal carcasses, tissues, and fluids contaminated with infectious agents that are <br /> contagious to humans, <br /> Surgical specimens: human or animal parts or(Issues removed surgically or by autopsy that are contaminated with <br /> infectious agents that are contagious to humans or In a fixative(e.g.formaldehyde), <br /> Isolation Wastes: waste contaminated with excretion, exudates, or secretions from humans or animals that are <br /> isolated due to highly communicable diseases. <br /> Chemotherapy Wastes:waste contaminated through contact with chemotherapeutic agents. <br /> 1. Does your business or service generate any of the medical waste listed above? j Yes ONO <br /> If your answer is"No", please complete the "Certification Statement" on Page 3 and return It <br /> with this questionnaire to the address indicated. You do not need to complete the remainder of <br /> this questionnaire and you do not need to pay a fee, <br /> 2. Do you generate less than 200 pounds of medical waste per month? CI Yes'&No <br /> If you answered"Yes",you are a small generator. , <br /> 3. Small generators may store their medical waste in a permitted Common <br /> Storage Facility with other small generators. Do you plan to do this at your <br /> facility? ®Yes No <br /> If your answer Is"Yes",you must obtain a"Common Storage Facility Permit"from this office. <br /> 4. Do you plan to treat your medical waste onsite (at your facility), by autoclaving, Incinerating or <br /> using microwave technology? Yes I]No <br /> If you are a small generator and your answers to question 3 &4 are "No", then complete the <br /> "Certification Statement" on Page 3 and return it with this questionnaire to the letterhead <br /> address. You do not need to complete the rest of this package. <br /> If your answer Is"Yes", you must complete Pages 4-7 and return them with this questionnaire <br /> and the appropriate fee(see Page A)to the address Indicated on Page 1. <br /> I <br /> i <br /> 2 of 8 <br />