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ORM �TRI_5 <br />Please the appropriatefor thequestions listed below. <br />REGULATED NEDICAL WASTES <br />Laboratory Wastes - specimen • microbiologic cultures, st• of • • <br />us agents, <br />live tattenuatedvaccines, • •culturemediums <br />• •r <br />humanBlood or Body Fluids - liquid blood elements or other regulated body fluids, or <br />articles contaminated with blood or body fluids <br />&arps - syringes, needles, blades, broken glass materials <br />Contaminated Animals - animal carcasses, body parts, beddin <br />Surgical Specimens - • animal r. • tissues•• • • • <br />autopsy <br />above?isolation Wastes - waste contaminated with excretion, exudate, or secretions from <br />humans or animals who are isolated due only to the highly communicable diseases <br />listed by Centers for Disease Control as requiring Biosafety Level 4 precautions.* <br />Does your business or service generate any of <br />tke medical wastes listed ." • <br />Page <br />If your answer is no. please complete the "Cerffication Statemenf on 5 and return it wiii�t�is questionnaire to the address indicated. You do not <br />need • complete the remat y . of questionnaire. <br />If your answer is m please check the types(s) of waste listed above that <br />you or your facility generate. Please complete the rest of this questionnaire. <br />2. D• you generate lessthan 200 pounds of • • <br />ical <br />waste per • you • <br />generator. <br />3. Small generatorsmay •. r • <br />ical waste <br />in a permitted • i#r storagefacility• <br />other small generators. Do you plan to do this <br />at your facility? ye4_no_2/ <br />if your answer is 3M a PHS-EHD • irril.• r StorageFacility Permit <br />Application7 wM be mailed to you. Please• you want <br />r <br />application -r elsewhere. <br />-CONIUqM ON REVERSE <br />3 <br />