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09/06/2012 14:49 209473"12f)9 BUSNINESSOFFI PAGE 02/06 <br /> F <br /> PRE-APPLICATION QUESTIONNAIRE <br /> Regulated Medical Wastes <br /> Tease check the appropriate box for the questions listed below: <br /> ]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(8)(1)]. This definition does not include RCRA waste. <br /> ❑ Laboratory Wastes: specimen or microbiologic cultures, stocks of infectious agents, live and attenuated <br /> vaccines and culture mediums. <br /> )Blood or Body'Fluids: liquid blood elements, other regulated body fluids, articles contaminated with blood <br /> or body fluids. <br /> Sharps:syringes,needles,blades and contaminated broken glass. <br /> ❑ Contaminated.A.tahnals: animal carcasses,body parts and bedding materials. <br /> ❑ Surgical Specimens: human or animal parts or tissues removed surgically or by autopsy. <br /> Isolation 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 for Disease Control as <br /> requiring Biosafety Level IV precautions. <br /> 1. Does your business or service generate any of the medical waste listed above? Yes❑No <br /> if your answer is "No", please complete the "Certification Statement" on Page 4 <br /> and return it with this questionnaire 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? ❑YesNo <br /> 1f you answered"Yes",you are a small generator. <br /> 3. Small generators may store their medical waste in a permitted Common Storage <br /> Facility with other small,generators. Do you plan to do this at your facility? ❑Yes N1 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 autoclaving, <br /> incinerating or using microwave technology? ❑YesNo <br /> If you are a small generator and your answers to question 3 & 4 are "No", then <br /> complete the "Certification Statement" on Page 3 and return it with this <br /> questionnaire to the letterhead address. You do not need to complete the rest of this <br /> package. <br /> If your answer to this question is "Yes", you must complete pages 4 & 5 and return. <br /> them with this questionnaire and the appropriate fee to the address indicated on Page <br /> 1. <br /> 5. If you generate less than 20 pounds of 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 Limited Quantity Mauling Exemption from this office. This <br /> exemption allows you or your staff to transport medical waste to a medical waste <br /> treatment facility. Do you want to apply for a Limited Quantity Bauling Exemption? ❑Yes No <br /> TsUD 45-03 2 <br /> Received Time Sep, 6. 2012 2: 45PM No, 0247 <br />