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1 R c 1 1 A ,; \ ,r' <br />Regulated Medical <br />Please check the appropriate box for the questions listed below: <br />r g U <br />PcRl`,"JOT?` SERVICES <br />❑ Laboratory Wastes: specimen or microbiologic cultures, stocks of infectious agents, live and <br />attenuated vaccines and culture mediums. <br />Blood or Body Fluids: liquid blood elements, other regulated body fluids, articles contaminated with <br />P( blood or body fluids. <br />Sharps: 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 />❑ Isolation Wastes: waste contaminated with excretion, exudates, or secretions from humans or animals <br />who are isolated due only to the highly communicable diseases listed by the Centers for Disease <br />Control as requiring Biosafety Level IV precautions. <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 <br />4 and return it with this questionnaire to the address indicated. You do not need <br />to complete the remainder of this questionnaire. <br />2. Do you generate less than 200 pounds of medical waste per month? ❑ YeAll, o <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 obtain 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 LYNo <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 <br />this package. <br />If your answer to this question is "Yes", you must complete Pages 4 & 5 and <br />return them with this questionnaire and the appropriate fee to the address <br />indicated on Page 1. <br />If you generate less than 20 pounds of medical waste per week, transport less <br />than 20 pounds at one time, and have a hauling information document on file in <br />your office, you may apply for a Limited Quantity Hauling Exemption from this <br />office. This exemption allows you or your staff to transport medical waste to a <br />medical waste treatment facility. Do you want to apply for a Limited Quantity <br />Hauling Exemption? ❑ Yes No <br />E;Ho 45-02-003 web Page 2 of 7 <br />R 14!07 <br />