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r. r r r : OQUESTIONNAIRE <br />Please check, theappropriate r• for questions y•• • below. <br />REGULATED MEDICAL <br />Laboratory Wastes - specimen or microbiologic cultures, stocks of infectious agents, <br />live and attenuated vaccines, and culture mediums <br />Blood or Body Fluids - liquid blood elements or other regulated body fluids, or <br />articles contaminated with blood or body fluids <br />Sharps - syringes, needles, blades, broken glass <br />Contaminated i ff s animalcarcasses, ?-i f parts, bedding materials <br />Surgical Specimens - human or animal parts or tissues removed surgically or by <br />autopsy <br />Isolation <br />humans or animals who are isolated due only to the highly communicable diseases <br />listed by Centers for Disease Control as requirmig Biosafery Level 4 precautions.* <br />1. Does your business or service generate any of <br />the medical wastes listed above? yes no— <br />If your answer is no, please complete the "Certification Statenume on <br />. <br />age <br />s and return it with this questionnaire to theaddressindicated. You •i not <br />need to complete the remainder of this questionnaire. <br />if your answer is yrs please check the types(s) of waste listed above that <br />you or your facility generate. Please complete the rest of this questionnaire. <br />2. Do you generate less than 200 pounds of medical <br />waste per <br />m • yes, youare <br />generator. <br />3. Small generators may store their medical waste <br />in a permitted common storage facility with <br />other small generators. Do you plan to do this yes_no— <br />your facility? <br />If your answer is 3M a i"Common Storage FacilityPermit <br />Applicati=7 will be mailed to you. Please indicate if you want the <br />application mailed elsewh_ _ <br />-CONTZMED ON E" <br />P <br />