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0 0'0N W' Z ZIOZ til '4nd awi1 P;AI;3;� <br />PRE -APPLICATION <br />Ii `t 3♦., QUESTIONNAIRE <br />,,.., <br />Regulated Medical <br />Please check the appropriate box for the questions listed below: <br />.Pharmaceuticals: prescription or over-the-counter human or veterinary drug, including, but not limited to, a <br />drug as defined in Section 109925 or the Federal Food, Drug, and Cosmetic Act, as amended, (21 O.S.C.A. <br />Sec_ 321(g)(1)]. This definition does not include RCRA waste. <br />❑ Laboratory Wastes: specimen or microbiologic cultures, stocks of infectious agents, live and attenuated <br />vaccines and culture mediums. <br />[� Blood or Body Fluids: liquid blood elements, other regulated body fluids, articles contarninated with blood <br />or body fluids. <br />[� Sharps: syringes, needles, blades and contaminated broken glass. <br />❑ Contaminated Animals: animal carcasses, body parts and bedding materials. <br />❑ Surgical Specimens: human or animal parts or tissues removed surgically or by autopsy. <br />dIsolation Wastes: waste contaminated vvith excretion, exudates, or secretions frorn humans or animals who <br />are isolated due only to the highly communicable diseases listed by the Centers for Disease Control as <br />requiring Biosafety Level 1V precautions_ <br />1. Does your business or service generate any of the medical waste listed above? ZYes ❑ No <br />If your answer is "No", please complete the "Certification Statement" on Page 4 <br />and return it with this questionnaire to the address indicated. You do not need to <br />complete the remainder of this questionnaire and you do not need to pay a fee. <br />2. Do you generate less than 200 pounds of medical waste per month? ❑ Yes dNo <br />If you answered "Yes", you are a small generator. <br />3. Small generators may store their medical waste in a permitted Common Storage <br />Facility with other small generators. Do you plan to do this at your facility? E] Yes [o <br />If your answer is "Yes", you must obtain a "Common Storage )Facility Permit" <br />from this office. <br />4. Do you plan to treat your medical waste onsite (at your facility), by autoclaving, <br />incinerating or using microwave technology? Yes dNo <br />If you are a small generator and your answers to question 3 & 4 are "No", then <br />complete the "Certification Statement" on Page 3 and return it with this <br />questionnaire to the letterhead address. You do not need to complete the rest of this <br />package. <br />If your answer to this question is "Yes", you must complete Pages 4 & 5 and return <br />them with this questionnaire and the appropriate fee to the address indicated on Page <br />1. <br />5. If you generate less than 20 pounds of medical waste per week, transport less than 20 <br />pounds at one time, and have a hauling information document on file in your office, <br />you may apply for a Limited Quantity Hauling Exemption from this office. This <br />exemption allows you or your staff to transport medical waste to a medical waste <br />treatment facility. Do you want to apply for a Limited Quantity Hauling Exemption'? ❑ Yes dNo <br />El -ID 45-03 <br />6/14/07 <br />2 <br />OL/£ d Z6£8 MO? << 5�:: L �L-80-ZLOZ <br />