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PRE-APPLICAMON QUESTIONNAIRE <br /> Please check the appropriate response for the questions listed below. <br /> REGULATED MEDICAL WASTES <br /> OLaboratory Wastes- spec' a or n-dcrobiologic cultures, stocks of infectious agents, <br /> live and attenuated vaccines, and culture mediums <br /> ( ) <br /> Blood or Body Fluids - liquid blood elements or other regulated body fluids, or <br /> articles contaminated with blood fluids <br /> Sharps - syringes, needles, blades, broken glass <br /> OContaminatedAnimals <br /> - al carcasses, body parts, bedding materials <br /> O - or animal parts or tissues removed surgically or by <br /> autopsy <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 Centers for Disease Control as requiring Biosafety Level 4 precautions.* <br /> 1. Does your business or service generatey of <br /> the medical wastes listed above? yes q_ <br /> If your answer is no, please complete the%" tion Stat t" on Page <br /> S and ret it with this questionnaire to the address indicated. You do not <br /> need to complete the remainder of this questionnaire. <br /> If your wer is yes, please check the es(s) of waste listed above that <br /> you or your facility generate. Please complete the rest of this questionnaire. <br /> 2. Do you generate IpZ than 200 pounds of medical <br /> waste per month?�If yes, you are a small <br /> generator. yes X no® <br /> 3. Small generators may store their medical waste <br /> in a permitted common storage facility 'th <br /> other small generators. Do you plan to do this <br /> at your facility? yes—no <br /> If your answer is PHS- D "Common Storage r-acility Permit <br /> Application!' a mailed you. Please indicate if you want the <br /> application mailed elsewhere. <br /> -CONTINUIM- ON • •ItSB- <br />