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Adwmwh� <br /> LES 'ON NV*l 6lE -[Z -unr aur A I <br /> SAKJOAOUIN Environmental Kea.fth Department <br /> C 0 U N TY",......... <br /> PRE-APPLICATION QUESTIONNAIRE <br /> Regulated Medical Wastes <br /> Plea e 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 drug as <br /> defined in Section 109925 of the Federal Food, Drug,and Cosmetic Act, as amended(2-1 U.&C.A.Sec., 321(g)(1)]. <br /> This definition does not include RCRA waste.. <br /> ❑ Laboratory Wastes,.specimen or microbiologic cultures, stocks of infectious agents, live and attenuated vaccines <br /> and culture mediums. <br /> Blood or Body Fluids; liquid blood elements, other regulated body fluids, articles contaminated with blood or body <br /> fluids. <br /> Sharps. syringes, needles, blades and contaminated broken glass. <br /> Contaminated Animals: animal carcasses, tissues, and fluids contaminated with infectious agents that are <br /> contagious to humans. <br /> [j Surgical Specimens:human or animal parts or tissues removed surgicaliy:or by autopsy that are contaminated with <br /> infectious agents that are contagious to humans or in a fixative(e.g. formaldehyde). <br /> Isolation Wastes: waste contaminated with excretion, exudates, or secretions from humans or animals that are <br /> Isolated due to highly communicable diseases. <br /> Chemotherapy Wastes:waste contaminated through contact with chemotherapeutic agents. <br /> 1. Does your business or service generate any of the medical waste listed above? dyes []No <br /> If your answer is "No", please complote'the"Certification Statement"on Page 3 and return it <br /> with this questionnaire to the address indicated, You do not need to complete the remainder of <br /> 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? 0 Yes[�No <br /> If you answered"Yes", you are a small generator. <br /> 3, Smell generators may store their medical waste in a permitted Common <br /> Storage Facility with other small generators. Do you pl8n to do this at your <br /> facility? 0 Yes No <br /> If your answer is"Yes", you must obtain a "Common Storage Facility Permit"from this office.. <br /> 4, Do you plan to treat your medical waste onsite (at your facility), by autoclaving, incinerating or <br /> using microwave technology? E]Yes No <br /> If you are a small generatorjIld your answers to question 3 & 4 are "No", then complete the <br /> "Certification Statement" on Page 3 and return it with this questionnaire to the letterhead <br /> address. You do not need to complete the rest of this package. <br /> if your answer is 'Yes", you must complete Pages 4-7 and return them with this questionnaire <br /> and the appropriate fee (see Page 8)to the address indicated on Page 1, <br /> 2 018 <br />