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MAY-03-11 09:21 FROM- of T-093 P.05/13 F-462 <br /> PRE-APPLICATION QU S'T NNA <br /> Regulated Medical Wastes <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.C.A. <br /> Sgc.321(g)(1)]. This definition does not include RCRA waste. <br /> ol/Laboratory Wastes: specimen or microbiologic cultures, stoCks of infectious agents, live and attenuated <br /> vaccines and culture mediums. <br /> ood or Body Fluids; liquid blood elements, other regulated body fluids, articles contaminated with blood <br /> M/body fluids. <br /> Sharps;syringes,needles,blades and contaminated broken glass. <br /> ❑ Contaminated Animals:animal carcasses,body parts and bedding materials. <br /> � Isoiafion <br /> S rgical Specimens:human or animal parts or tissues removed surgically or by autopsy. <br /> 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 /> our business or service,generate any of the medical waste listed above? Ycs�]No <br /> I. Does y <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 /> 'c per month? ❑Y IVo <br /> 2. Do you generate less than 200 pounds of medical waste p <br /> If 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 aillo <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? p Yes[}�0 <br /> If you are a small generator _aPA 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 retam <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 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 <br /> EHTU 45-03 2 <br /> 6114/07 <br />