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PRE-APPLICATION QUESTIaNN,AME SEP 2 ° F <br /> Please check the appropriate response for the questionslisted below P E*R m!:r/S4,E R V i <br /> MEDICALREGULATED S <br /> ( to -specimen 'c ioo 'c cultures, stocks of infectious agents, <br /> live and attenuated vaccines, culture mediums <br /> ( lood or Body Fluids - liquid to ets or other regulated body fluids, or <br /> articles contaminated blood r body fluids <br /> ( Sharps - syringes, needles, blades, broken glass <br /> OContaminated Animals - animal carcasses, body parts, bedding materials <br /> ( Sical - or s or tissues removed surgically or by <br /> autopsy r n �. <br /> OIsolation Wastes - waste contaminated excretion, exudate, or secretions from <br /> humans oranimals o are isolated due only to the y communicable diseases <br /> listed by Centers for Disease Control as requiring Biosafety Level 4 precautions.* <br /> 1. Does your business or servicegenerate y of <br /> the medical to listed above? y ✓o <br /> If your answer is no, please complete the "Certification Stat t" on Page <br /> 5 and return it with this questionnaire to the address indicated. You do not <br /> need to complete the remainder of this questionnaire. <br /> If youranswer is 3M pleasec e es(s) of waste listed above that <br /> you or your facility generate. Please complete the rest of this questionnaire. <br /> . Do you generate less than 200 pounds of medical <br /> waste permonth? If yes, you are a small <br /> generator. yes® o t� <br /> 3. Small generators may store their medical waste <br /> in a permitted common storage facility 'th <br /> other small generators. Do you plan to do this <br /> at your facility? yes no , <br /> If youranswer is "Common Storage Facility Pernit <br /> p " 'o ' will be mailed to you. Please indicate if you want the <br /> application mailed elsewhere. <br /> -CONTINUED ON E- <br />