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Mir- <br /> PIZE-APPLICATION QUESTIONNAIRE <br /> llegtdatcd Medical Wastes <br /> Please check the appropriate box for the questions listed below: <br /> El Pharmaceuticals: Prescription or over-the-counter human or veterinary drug, including, but not limited to,a <br /> drug as defined in Section 109925 of the Federal Food, Drug, and Cosmetic Act, as amended (21 U.S.C.A. <br /> -Sec- 321(g)mj. This definition does not include RCRA waste. <br /> El 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 contaminated with blood <br /> or body fluids. <br /> Sharps: syringes,needles,blades and contaminated broken glass. <br /> El Contaminated Animals: animal carcasses, tissues, and fluids contaminated with infectious agents that are <br /> contagious to humans. <br /> ❑ it <br /> Surgical Specimens: human or animal parts or tissues removed surgically or by autopsy that are <br /> contaminated with infectious agents that are contagious to humans or in a fixative(e.g. formaldehyde). <br /> ❑ Isolation Wastes: waste contaminated with excretion, exudates, or secretions from humans or animals that <br /> are isolated due to highly communicable diseases. <br /> ❑ Chemotherapy Wastes:waste contaminated through contact with chemotherapeutic agents. <br /> Does your business or service generate any of the medical waste listed above? Yes❑No <br /> If your answer is "No", please complete the "Certification Statement" on Page 3 <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 XNo <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? 0 Yes No <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, Yes <br /> incinerating or using microwave technology? <br /> No <br /> If you are a small generator and your answers to question 3 & 4 are "No", then <br /> coll,plete tile "Certification Statement,, on Page 3 and return it %vith this <br /> qucstionnaire to the letterhead address. You do not need to complete the rest of this <br /> package. <br /> If your answer is "Yes", you must complete Pages 4-8 and return them %vith this <br /> questionnaire and the appropriate fee(see page 9)to the address indicated on Page I <br /> FAID 45-03 2 <br /> 2015 <br /> L <br />