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09/07/99 22:47 Z 209 9574142 TRIGUERO P.03 <br /> KLJ(I <br /> PRE-APPLICATION QUESTIONNAIRE <br /> REGULATED MEDICAL WASM <br /> (cba*so ON w1y) <br /> LaborAtury Wast= - s9mlincrt or tui crubiolojOc cWtuacs, stocks of im&cdous agents, live aad <br /> attenuated vaccines,and caluav mediums <br /> Blood or Body Flulds - liquid blood elements orother regulated body fluids, or articles <br /> contam:inxted wi*blood or body fluids <br /> Sb"e -syrinSes,needles,blades,broktm&,lass <br /> Coma ted Avbmls -=!Ewd carcasses,body parts,bedding materials <br /> Sar ' Specimem-human or animal parti or tissues removed surgically or by autopsy <br /> Isolation Wastes - to contaatinated with ex tion, exudsa, or secietions from humans or <br /> admals who am isolated due only to the higWy communicable dismes listed by Centers for <br /> Disease Control as tequiring Isiosafety Level 4*precautions. <br /> 818.ft "WWWA*"WON& <br /> 1. Does your busiioess.or service generate any of the medical wastes listed above? yesv'w_ <br /> If your answer is V& please complete the "Cerfification Statemeur' on Pap 3 and mtum it with this <br /> questionnaire to the address indicateJ. You do not aatd to complete the mmaindcr of this questionnaire. <br /> If your answer is ves - qjx-.�s) of waste listed above dw you or your facility genemte. <br /> , please check the <br /> Plow complete the smt of this queWonaairt. <br /> V/ *,kN4 C�A-?f <br /> 2. Do you generate 200 pounds or more of medic al waste per month? yes_ no— 1,0414 1j <br /> to treat your medical waste <br /> Do you ph (at your facility), by autoclaving, incinerating or <br /> using microwave technoloW. yos,_aoi7li <br /> If your arawers to- 17t as 3 are MZ then co leve the 'TwWcAtion Statement"on Pap 3 and <br /> rct=It with this questionnaireto the addrms shown&t the bottom of Pago I- <br /> If your answers tog co tete the "Registration/Permit Application For <br /> MaUcal Waste" form on Page 4 and submit a"WI edical to Man;atement Pbol" as specified on <br /> Page 5. <br /> 4. If you <br /> .cncrAx less than 20 pounds of medical waste per week,musporr Im dum 20 pounds <br /> at one tixae,and haft a hauling idormation document on We in your office,you may apply <br /> for a Limited Quaafity HaWing Exemption. 11is examption allows you or your staff to a=pw <br /> medical waste to a med1W waste tc2dintut oc to a consolidation point uatU it can be <br /> removed by a mgLitered medicitl waste hauler. Do you waut to apply for a Limited Quactity <br /> H Exemption? yaszfto- <br /> If your answer is M a"Limited Randal;Exemption"application will be mailed w you. <br /> 2 <br />