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Lodi Memorial West <br />ISI E-APPUC ATION QU=0NNAJ-PT--. <br />n - <br />MAY 1092 <br />ENVJRONNAUJA� <br />PER <br />M i I 'T / S E R`V3 <br />Please che,,-.k the appropriate response for the questions; listed below. <br />RE, GULATED MFDICAI. WASIT-S <br />Labonatory Wa-stes - specimen or inicrobiologic cultures, stocks of infectious agexits,, <br />live mid all-tenuated vaccines, and culture mechiims <br />BRx>d. or Body Flia ds - liquid blood elements or other regulated body fluids, or <br />arcicl.-s containinzaed vntlh blood. or body fluids <br />Sh;a-,Tps neeffles, blades, brolc,ii glass <br />Contmninated Anintals - anlaial carcasses, body parts, bedding, materials <br />.qty <br />Specimem - human or ar�mal parts or tissues removed survically or by <br />S op <br />tsy <br />Isolation 'Was t es - w,--iste contaminated with excretion, exudate, or secretions from <br />I h -ru-r uni ases <br />-,mans carcable disc <br />1 -ii Z Is who are isolated due only to the hig hey coi i <br />listed by Centers for Disease Control as requiTing 13iosafety level 4 precautions.* <br />1. Does your business or service generate wmy of <br />4110 <br />the 'C' wastes i <br />lsted al)ave? yes <br />- <br />ffyo?ara-,-vswerisn please complete the "Certifica-tio,.iState i�ricnt"ozi Page <br />5 and rctun-.t it with this questionnaire to the address indicated. You do not <br />TIcdto coxciiplete the remainder of this questionnaire. <br />If` <br />your answer is ye,- please check the types(s) of waste, listed above that <br />you or your facility gencrata. Please complete the rest of this questionnaire. <br />2. Do you generate less than 200 pounds of rriedical <br />waste per month? if yes, you are a small <br />gener,ator. yes.__no® <br />3. Small generators rnay store their medical waste <br />i -i a pemiitted common storage f"Acility +i�ith <br />other small gencratoi's. Do you Olar, to do this <br />at your facility? yes,—nox <br />If your answer is a IHS- I- "Conur-on Storage Facility Permit <br />Application" will be rou-dle.d tc.) you. Please indicate if you want the <br />applicatioi, mailed elsewhere. <br />-00NT1P,,1UE,D ON IUET�,TUISZ- <br />io <br />