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II (b) <br /> TYPES OF REGULATED MEDICAL WASTE FACILITY GENERATES: <br /> (Check those that apply) <br /> Laboratory waste: <br /> Specimen or microbiologic cultures, stocks of infectious agents, live <br /> and attenuated vaccines, and culture mediums <br /> Blood or body fluids: <br /> Liquid blood elements or other regulated body fluids, or articles <br /> contaminated with blood or body fluids <br /> (V� Sharps: <br /> Such as, syringes, needles, blades, broken glass items, glass slides, <br /> acupuncture needles, root canal files <br /> Contaminated animals: <br /> Animal carcasses, body parts, bedding materials <br /> Surgical specimens: <br /> Human or animal parts or tissues removed surgically or by autopsy <br /> Isolation waste: <br /> Waste contaminated with excretion, exudate., or secretions from humans or <br /> animals who are isolated due to highly communicable diseases. <br /> REQUIRED REGISTRATION INFORMATION: <br /> 1. How many pounds of medical waste does your facility generate per month? <br /> (Tracking documents must be kept on file and are subject to audit. ) <br /> <QO -lbs <br /> 2. Place a 11 X 11 next to the corresponding method your facility uses to <br /> dispose of medical waste. <br /> Autoclave (onsite treatment) <br /> Incinerate (onsite treatment) <br /> Microwave Technology ( onsite treatment) <br /> Authorized Medical Waste Transporter <br /> (Name of Transporter) <br /> Alternative Technology (refer to alternative technology list) <br /> (Name of Treatment Method) <br /> (ci,rxrl\e one) <br /> 3 . Yes No Do you want to apply for a Limited Quantity Hauling Exemption? <br /> You may qualify for the exemption if you generate less than 20 <br /> pounds of medical waste per week and not more than 80 pounds <br /> per month. Refer to Section 25061 of the California Health & <br /> Safety Code for requirements. <br /> I declare under penalty of law that to the best of my knowledge and belief <br /> the statements made herein are correct and true. I hereby consent to all <br /> necessary inspections made pursuant to the California Medical Waste <br /> Management Act and incidental to the issuance of the Registration/Permit and <br /> the operation of this business. <br /> ATE: SWAP <br /> SIGNATURE: <br />