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• <br /> SA J O n Q U I N Environmental Health Department <br /> ----C O U N T Y <br /> ---- <br /> PRE-APPLICATION QUESTIONNAIRE <br /> Regulated Medical Wastes <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 drug as <br /> defined in Section 109925 of the Federal Food, Drug, and Cosmetic Act, as amended [21 U.S.C.A. Sec. 321(g)(1)]. <br /> This definition does not include RCRA waste. <br /> [�Laboratory Wastes: specimen or microbiologic cultures, stocks of infectious agents, live and attenuated vaccines <br /> and culture mediums. <br /> T( Blood or Body Fluids: liquid blood elements, other regulated body fluids, articles contaminated with blood or body <br /> fluids. <br /> Sharps: syringes, needles, blades and contaminated broken glass. <br /> ❑ Contaminated Animals: animal carcasses, tissues, and fluids contaminated with infectious agents that are <br /> contagious to humans. <br /> ❑ Surgical Specimens: human or animal parts or tissues removed surgically or by autopsy that are contaminated with <br /> infectious agents that are contagious to humans or in a fixative (e.g. formaldehyde). <br /> I/ Isolation Wastes: waste contaminated with excretion, exudates, or secretions from humans or animals that are <br /> isolated due to highly communicable diseases. <br /> ❑ Chemotherapy Wastes:waste contaminated through contact with chemotherapeutic agents. <br /> 1. Does your business or service generate any of the medical waste listed above? P�Yes []No <br /> If your answer is"No", please complete the "Certification Statement" on Page 3 and return it <br /> with this questionnaire to the address indicated. You do not need to complete the remainder of <br /> 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 iy�No <br /> If you answered "Yes", you are a small generator. <br /> 3. Small generators may store their medical waste in a permitted Common <br /> Storage Facility with other small generators. Do you plan to do this at your <br /> facility? ❑Yes Oo <br /> If your answer is"Yes", you must obtain a"Common Storage Facility Permit"from this office. <br /> 4. Do you plan to treat your medical waste onsite (at your facility), by autoclaving, incinerating or <br /> using microwave technology? ❑Yes No <br /> If you are a small generator and your answers to question 3 & 4 are "No", then complete the <br /> "Certification Statement" on Page 3 and return it with this questionnaire to the letterhead <br /> address. You do not need to complete the rest of this package. <br /> If your answer is "Yes", you must complete Pages 4-7 and return them with this questionnaire <br /> and the appropriate fee(see Page 8)to the address indicated on Page 1. <br /> 2 of 8 <br />