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Iq <br /> APR-06-11 10:33 FROM- T-853 P.05/19 F-873 <br /> PRE-A-PPLICATION QUESTIONNAIRE <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 /> See.321(8)(1)]. This definition does not include RCRA waste. <br /> 04aborxtory Wastes: specimen or microbiologic culrures, stocks of infectious agents, live and attenuated <br /> es and culture mediums. <br /> fl <br /> ecmood or Body Fluids: liquid blood elements, other regulated body fluids, articles contaminated with blood <br /> �body fluids. <br /> liarps:syringes,needles,blades and contaminated broken glass. <br /> [] Contaminated Animals:animal carcasses,body parts and bedding materials_ <br /> �Zlso' <br /> gmii Specimens:human or animal parts or tissues removed surgically or by autopsy. <br /> lation Wastes: waste contaminated with excretion, exudates, or secretions from humans or animals who <br /> are isolated due only to the highly communicable diseases lasted by the Centers for Disease Control as <br /> requiring Biosafety Level 1V precautions. <br /> 1_ Does your business or service generate any of the medical waste listed above? es©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 /> Yos No <br /> 2. Do you generate less than 200 pounds of medical waste per month. <br /> Q <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 o <br /> If your answer is "Yes", you must obmin 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? ❑Yes�, "" <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 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 a<011 <br /> FHn 45.09 2 <br /> 6114/07 <br />