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PRE-APPLICAMON QUESTIONNAIRE <br /> Please check the appropriate response for the questions listed below. <br /> MEDICALREGULATED S <br /> ( ) Laboratory Wastes-specimen or 'croiologic cultures, stocks of infectious agents, <br /> live and attenuated vaccines, and culture mediums <br /> (x) Blood or Body Fluids - liquid blood elements or other regulated body fluids, or <br /> articles contaminated with blood or body fluids <br /> (yj Sharps - syringes, needles, blades, broken glass <br /> OContaminated Animalscarcasses, body parts, bedding materials <br /> ( ) Surgical S - human or animalp s or tissues removed surgically or by <br /> autopsy <br /> (x) isolation Wastes - waste contaminated 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 Bios ety Level 4 precautions.* <br /> 1. Does your business or service generate any of <br /> the medical wastes listed above? yes x no^ <br /> If your er is no please complete the "Certification Statement" on Page <br /> S and return it with this questionnaire to the address indicated. You do not <br /> need to complete the remainder of this questionnaire. <br /> If your er is M please check the es(s) of waste listed above that <br /> you or your facility generate. Please complete the rest of this questionnaire. <br /> 2. Do you generate less' than 200 pounds of medical <br /> waste per month? If yes, you are a small <br /> generator. yes X o® <br /> 3. Small generators may store their medical waste <br /> in a permitted common storage facility with <br /> other small generators. Do you plan to do this <br /> at your facility? es—no X <br /> If .your answer is 3M a PHS- D "Common Storage Facility 't <br /> Application!' will be mailed to you. Please indicate if you want the <br /> application mailed elsewhere. <br /> -C REVERSE- <br />