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ae:j Ea to a4Je E s� <br /> 90.0 i1. h htao it St. <br /> Lodi�Caiifofnia 95240 <br /> PRE-APPLICAITON <br /> Please check the appropriate response for the questions listed below. <br /> REGULATED MEDICAL WASTES <br /> OLaboratory Wastes-specimen or 'croiolo 'c cultures, stocks of infectious agents, <br /> live and attenuated vaccines, and culture mediums <br /> O <br /> Blood or Body Fluids - liquid blood elements or other regulated body fluids, or <br /> articles contaminated blood or body fluids <br /> OSharps - syringes, needles, blades, broken glass <br /> Ont t - carcasses, body s, bedding materials <br /> O S - or animal parts or tissues removed surgically or by <br /> autopsy <br /> OIsolation Wastes - waste contaniinated 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 Bios a Level 4 precautions.* <br /> 1. Does your businessor service generate any o <br /> e medical wastes listed above? y nq_.-. <br /> If your answer is no, please complete the "Certification Stat t" on Page <br /> 5 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 (s) of waste listed above that <br /> you or your facility generate. Please complete the rest of this questionnaire. <br /> . Do you generate less than 200 pounds of medical <br /> waste per month? If yes, you are a small <br /> generator. yes o_ <br /> . Small generators may store their medical waste <br /> in a permitted common storage facility with <br /> others all generators. Do you plan to do this <br /> at your facility? yes-oleo' <br /> If youranswer is yes, a PHS- "Common Storage Facility Perm't <br /> Application!' will be mailed to you. Please indicate if you want the <br /> application mailed elsewhere. <br /> -CONTINUED ON R . E_ <br />