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0 <br /> PRE-APPLICATION 1U <br /> Regulated a ical Wastes <br /> Please check the appropriate bozo 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 ina Section; 109925 of the Federal Food, Drug, and Cosmetic Act, as amended [21 U.S.C_,A,. <br /> Scc.321(g)(I)]. 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, tissues, and fluids contaminated with infectious agents that are <br /> contagious to humans. <br /> ❑ Surgical Specimens: human or animal parts or tissues removed surgically or by autopsy that are <br /> contaminated with infectious agents that are contagious to humans or in a fixative(e.g.formaldehyde). <br /> ❑ I(Solation Wastes: waste contaminated with excretion, exudates, or secretions from humans or animals that <br /> are isolated due to highly communicable diseases.- <br /> Chemotherapy <br /> iseases:Chemotherapy Wastes:waste contaminated through contact with chemotherapeutic agents. <br /> 1. Does your business or service generate.any of the medical waste listed above? , Yes❑No <br /> If your answer is "No", please complete the "Certification. Statement" on Page 3 <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? ❑YesVO <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 ANO <br /> If your answer is "Yes", you must obtain a G°Commou 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? ❑Y--SX-NO <br /> cs-No <br /> If you are a small generator and your answers to question 3 & 4 are "No", then J�J <br /> complete the "Certification Statement" on Page 3 and return it with this <br /> questionnaire to the letterhead address. You do not meed to complete the gest of this <br /> package. <br /> If your answer is "Yes", you must complete Pages 4-8 and return them with this <br /> questionnaire and the appropriate fee(see Page 9)to the address indicated on Page I. <br /> L'C911 AG/17 <br /> Received Time Aug, 1, 2016 12: 57PM No- 1609 <br />