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0 <br />PRE -APPLICATION 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 />Sec. 321(g)(1)]. This definition does not include RCRA waste. <br />Laboratory Wastes: specimen or microbiologic cultures, stocks of infectious agents, live and attenuated <br />v cines and culture mediums. <br />Blood or Body Fluids: liquid blood elements, other regulated body fluids, articles contaminated with blood <br />or body fluids. <br />harps: syringes, needles, blades and contaminated broken glass. <br />❑ Contaminated Animals: animal carcasses, body parts and bedding materials. <br />❑ Surgical Specimens: human or animal parts or tissues removed surgically or by autopsy. <br />solation 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 />1. <br />3 <br />13 <br />EHD 45-03 <br />1/5/2006 <br />Does your business or service generate any of the medical waste listed above? <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 />Do you generate less than 200 pounds of medical waste per month? <br />If you answered "Yes", you are a small generator. <br />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? <br />If your answer is "Yes", you must obtain a "Common Storage Facility Permit" <br />from this office. <br />Do you plan to treat your medical waste onsite (at your facility), by autoclaving, <br />incinerating or using microwave technology? <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 />L <br />es❑No <br />❑ Yes MNo <br />■ <br />❑ Yes o <br />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 2<0- <br />2 <br />o <br />2 <br />