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tr hbfispe'-M alape Care Cerner <br /> 5XRO_Citronorl CIMIG <br /> PRE-APPLICATION QUESTIONNAMfg) <br /> on t o 952-jo <br /> Regulated Medical Wastes 473-Ii£it?4 <br /> Please check the appropriate box for the questions listed below: <br /> to Pharmaceuticals: prescription or over-the-counter human or veterinary drug, including, but not limited to, a <br /> drug as defined in Section 109925 or the Federal Food, Drug, and Cosmetic Act, as amended, (21 U.S.C.A. <br /> Sec, 321(g)(1)]. This definition does not include RC1tA waste. <br /> ❑ Laboratory Wastes: specimen or microbiologic cultures, stocks of hiructiou` agents, live and ,attenuated <br /> vaccines and culture mediums. <br /> Blood or Body Fluids: liquid blood elements, other regulaled body fluids, articles contaminated with blood <br /> or body fluids. <br /> Sharps: syringes,needles, blades and contaminated broken glass_ <br /> ❑ Contaminated Animals: animal carcasses, body parts and bedding materials. <br /> ❑ Surgical Specimens: human or animal pavtti or tissues removed surgically or by autopsy. <br /> holatiou Wastes: waste contaminated with excretion, exudates, or secretions from humans or animals who <br /> are isolated due only to the highly communicable diseases listed by the Centers fiir Discase Control as <br /> requiring Biosafety Level IV precautions. <br /> 1, rocs your business or service generate any of the medical waste Iisted above? Yue❑No <br /> If your answer is "No", please complete the "Certification Statement" on Pagc 4 <br /> and return it with ihis questinnnaire to the address indicated. You do not need to <br /> complete the remainder of 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? `Yw 0 <br /> No <br /> If you answered"Yes",you are a small generator. <br /> 3. Small generators may store their medical waste in a pennitted Common Storage <br /> Facility with other small generators. Do you plan to do this at your facility? ❑YesIX No <br /> If your answer is "Yes", you must obtain a "Common Storage Facility Permit" <br /> from this office. <br /> 4. Do you plan to treat your medical waste onsite (at your facility), by autoclavins, <br /> incinerating or using microwave technology'? ❑Ycs I No <br /> If you are a, small generator and your answers to question 3 & 4 are "Nt)", then <br /> complete the "Certification Statement'° on Pagc 3 and return it. with this <br /> question.nairc to the letterhead address. You do not need to complete the rest of this <br /> package. <br /> If your answer to this question is "Ycs",you must complete Pages 4&5 and return <br /> them with this questionnaire and the appropriate ice to the address indicated on Page; <br /> 1. <br /> 5. If you generate less than 20 pounds cif medical waste per week, transport less than 20 <br /> pounds at one time, and have a hauling information document on file in your office, <br /> you may apply for a 1_imited Quantity 'Hauling Exemption fron this offlice. This <br /> exemption allows you or your state'to transport medical waste to a medical waste: <br /> treatment facility. Do you want to apply for a Urreited Quantity Hauling Exempt.ioii7 ❑Yes%No <br /> rFln a,•p3 2 <br /> W1&07 <br /> 9T/2,d 262889t7:01 :WMId 0T:2T TT02_2T-AUW <br />