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PRE-APPLICATION QUESTIONNAIRE <br /> Please check the appropriate response for the questions listed below. <br /> REGULATED MEDICAL WASTES <br /> OLaboratory Wastes-specimen or 'croiolo 'c 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 blood or body fluids <br /> Sharps - syringes, needles, blades, broken glass <br /> Contaminated - carcasses, body parts, bedding materials <br /> ( ) S Specimens - or l parts or tissues removed surgically or by <br /> autopsy <br /> O <br /> Isolation Wastes - waste contaminated 't excretion, exudate, or secretions from <br /> humans or animals who are isolated due only to the highly communicable diseases <br /> listed by Centersfor Disease Control as requ=—' iosafe vel 4 precautions.* <br /> 1. Does your business or service eerte any of <br /> e medical wastes listed above? yes,/ng.— <br /> If your er is no, please complete the "Certification Stat t" on Page <br /> 5 and return it with this questionnaire to the address indicated. You do not <br /> need to complete the remainder of this questionnaire. <br /> If youranswer is yes please check e (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 permonth? If yes, you are a small <br /> generator. yes®no® <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 <br /> at your ac' ' ? ye :7, <br /> If your answer isyes - "Common to ge Facility Permit <br /> Application!' will be mailed to you. Please indicate if you want the. <br /> application mailed elsewhere. <br /> -CONTINUIM- ON E_ <br />