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N0.175 D02 05/10/2011 11,22 ' p _ , ,T r PRE-APPLICATION QUESTIONNAIRE 7-P-AlW1IV, Regulated ]Medical Wastes Please check the appropriate box for the questions listed below: Pharmaceuticals: prescription or over-the-counter human or veterinary dmg, including,but not limited to, a drug as defined in Section 109925 or the Federal Food, Drug, and Cosmetic Pict, as amended, [21 U.S.C.A. Sec.321(g)(1)), This definition does not include RCRA waste. ❑ Laboratory Wastes: specimen or microbiologic cultures, stocks of infectious agents, live and attenuated vaccines and culture mediums. Blood or Body Fluids: liquid blood elements, other regulated body fluids, articles contaminated with blood or body fluids. ❑ Sharpes syringes,needles,blades and contaminated broken glass. ❑ Contaminated Animals: animal carcasses,body.per and bedding materials. Surgical Specimens: human or animal parts or tissues removed surgically or by autopsy. ❑ Isolation 'Wastes: waste contaminated with excretion, exudates, or secretions from humans or animals who are isolated due only to the highly communicable diseases listed by the Centers for Disease Control as requiring Biosafety Level IV precautions. 1. Does your business or service generate a.ny of the medical.waste lister] above? Yes Q No if your answer is "No", please complete the "Certification Statemeat" on Page 4 and return it with this questionnaire to the Address indicated. You do not need to complete the remainder of this questionnaire and you do not need to pay a fee. 2. Do you generate less than 200 pounds of medical waste per month? Yes El Na If you answered"Yes",you are a small generator. 3. Small generators may store their medical waste in a permitted Common Storage Facility with other sinal I generators. Do you plan to do this at your facility? p ye No If your answer is "'Yes", you must obtain a `(Common Storage Facility Permit" from this office. 4. Do you plan to treat your medical waste onsite (at your facility), by autoclaving, incinerating or using microwave technology? ❑Yes No If you are a small generator and your answers to question 3 & 4 are "No", then complete the "Certification Statement" on Page 3 and return it with this questionnaire to the letterhead address. You do not need to complete tlie rest of this package. Lf your answer to this question is "Yes", you must complete Pages 4 & 5 and return them with this questionnaire and the appropriate fee to the address indicated.on Page 1. S. If you generate less than 20 pounds of medical waste per week,transport less than 20 pounds at one time, and have a hauling information document on file in your office, i you may apply for a. Limited Quantity Hauling .Exemption from this offce. This exemption allows you or your si:aFf to transport medical waste to a medical waste treatvnent facility. Do you want to apply:for a.Limited Quantity Hauling Exemption? ❑Yes Na EUD 45-03 2 cr,.AA i