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May. 11 2011 9.00AM Sax Joaquin County No. 1896 P. 3/9 <br />PRE -APPLICATION QUESTIONNA <br />Regulated MedicalWastes <br />Please 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.CA_ <br />Sec. 321(g)(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 Animals: animal carcasses, body parts and bedding materials. <br />❑ Surgical Specimens: human or animal parts or tissues removed surgically or by autopsy. <br />JQ 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 "N'o", 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.? El YesNo <br />If you answered "Yes", you are a small generator_ <br />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 ❑ 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? ❑ Ycs No <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 />I . <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 Hauling 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 Hauling Exemption? ❑ Yes'o No <br />45-03 2 <br />6/14/07 <br />