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f <br /> PRE-APPUCAnON QUESTIONNAIRE <br /> Please check the appropriate response for the questions listed below. <br /> REGULATED I WASTES <br /> ( ) Laboratory wastes en or microbiologic cultures, stocks of infectious agents, <br /> live and attenuated vaccines, and culture mediums <br /> (x) Blood or Body Fluids - liquid blood is or other regulated body fluids, or <br /> articles contaminated with blood or body fluids <br /> (x) Sharps - syringes, needles, blades,-broken glass <br /> ( ) Cont ted Animals - animal carcasses,.body parts, bedding materials <br /> O <br /> Surgical Specimens human or.animal parts or tissues removed surgically or by <br /> autopsy <br /> ( ) .Isolation Wastes waste.coxitaminatedwith excretion,.exudate, or secretions from <br /> humans or animals who are isolateddue*only to the highly.communicable diseases <br /> listed by Centers for Disease Control as requiring Biosafety Level 4 precautions.* <br /> 1. Does your business or service generate any of <br /> the medical wastes listed above? yes_xn®_. <br /> if,your answer.is.no,.pl c. . plete the "Certification Stat on Page <br /> S'and.return.it with-this, y 're to the address indicated: You do not <br /> need to.complete the remainder of.this questionnaire. <br /> If your answer is.3M please. the es(s) of waste listed above that <br /> you or your facility generate: Pleasecomplete.the rest of this questionnaire. <br /> 2. Do.youi generate Iess than 200 of medical <br /> waste per month? If yes, you are a smaU <br /> generator.. yes_no x <br /> 3. Small.generators may store their e <br /> in a permitted common storage facility with <br /> other small generators. Do you plan to do this <br /> at your facility? yes_no x <br /> If. your answer is ves.. a S-EHD "Common Storage T:acflity Permit <br /> Application". .will: be.mailed to you. Please indicate if you want the <br /> application mailed elsewhere. <br /> -CO REVERSE- <br /> 3 <br />