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PRE-APPLICATIGN QUESTIONNAIRE <br /> heck th Regulated Medical Wastes <br /> Please c <br /> ..e appropriate box for the questions listed below: <br /> Pharmaceuticals. prescription Or over-the-counter 11111-Dan or veterinary drug, including, but not limited to, <br /> drug as defined in Section 109925 or the Federal Food, Drug, and Cosmetic Act, as amended, [21 U.&C.A' .a <br /> See. 321(,g)(1)]. This definition does'lot include RCRA waste, <br /> Laboratory Wastes: specimen Or jilic"ObiOlOgic Cultures, stocks Of infectious agents, live and attenuated <br /> vaccines and Culture mediums. <br /> Blood or Body Fluids. liquid blood elelle'lls. Other regulated body fluids, articles contaminated with blood <br /> or body fluids. <br /> Sharps: syringes, needles, blades and contaminated broken glass. <br /> El Contaminated Animals: animal carcasses, body parts and bedding materials. <br /> EJ Surgical Specimens: human or animal parts Or tissues removed Surgically or by autopsy. <br /> Ev,r 1s0latiGH Wastes: waste contaminated with excretion, exudates, or secretions from hu.nians or animals who <br /> are isolated due only 10 the highly counilunicable diseases listed by the Centers for Disease Control as <br /> requiring Biosafety Level IV precautions. <br /> Z� <br /> 1. <br /> Does Your business or service generate any of the jiledica-1 waste listed above? <br /> If Your answer is "No", please complete the "Certification statement" on Page 4 No <br /> and return it with this clUCStiO.1111aire to [fie 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? Yes 0'�o <br /> If You answered "Yes",You area 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? g <br /> If your answer is "Yes", You must obtain a "Conlynou Storage Facility Permit" Yes <br /> fi-orn this office, <br /> 4. 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 aj)StNlej-s to question 3 & 4 are "No", then Yes 9K0 <br /> complete the "(certification Statenielit" oil Page 3 and return it with this <br /> questionnaire to the letterhea 1 11 <br /> package, d address. You do 'lot need to complete the rest of this <br /> If Your answer to this question is ,yes-, Oil Must complete Pages 4 & 5 and return <br /> 111c"ll with this questionnaire and the appropriate RT to the address indicated oil Pe <br /> I. <br /> Page <br /> 5. If You generate less than 20 pounds of medical waste per week,transport less than 20 <br /> pounds at one brine, and have a hauling inl'orniation document on file in Your office, <br /> You may apply for a Limited Quantify "an"119 ExenlPfi0l) from this office. '3'h <br /> is waste to a medical waste <br /> exemption allows You or your staff to transport medical is <br /> treatment facility. Do you want to appiv for a.Limited Quantity Iia.ulhig Exemption? f- <br /> jy s <br /> FH 1-,)45-Q3 <br /> 6/14/07 2 <br />