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PREOPPLICATION QUEST104AIRE <br /> Please mark the appropriate response for the questions listed below. <br /> REGULATED MEDICAL WASTES <br /> Laboratory Wastes —specimen or microbiologic cultures, stocks of infectious agents, live <br /> and attenuated vaccines, and culture mediums <br /> Blood or Body Fluids — liquid blood elements or other regulated body fluids, or articles <br /> contaminated with blood or body fluids <br /> Sharps — syringes, needles, blades, contaminated broken glass <br /> ❑ Contaminated Animals — animal carcasses, body parts, bedding materials <br /> ❑ Surgical Specimens— human or animal parts or tissues removed surgically or by autopsy <br /> ❑ Isolation Wastes —waste contaminated with excretion, exudates, or secretions from <br /> humans or animals who are isolated due only to the highly communicable diseases listed by <br /> the Centers for Disease Control as requiring Biosafety Level IV precautions. <br /> 1. 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 4 and return it <br /> with this questionnaire to the address indicated. You do not need to complete the remainder <br /> of this questionnaire. <br /> 2. Do you generate less than 200 pounds of medical waste per month? YES NO_ <br /> If you answered "YES", you are a small generator. <br /> 3. Small generators may store their medical waste in a permitted common storage facility with <br /> other small generators. Do you plan to do this at your facility? YES_ NO <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, incineratin , <br /> or using microwave technology? YES_ NO <br /> If you are a small generator and your answers to questions 3 & 4 are "NO", then complete <br /> the "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 to this question is "YES", you must complete Pages 4 & 5 and return them <br /> with this questionnaire and the appropriate fee to the address indicated on Page 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, you may <br /> apply for a Limited Quantity Hauling Exemption from this office. This exemption allows you <br /> or your staff to transport medical waste to a medical waste treatment facility. Do you want to <br /> 11, <br /> apply for a Limited Quantity Hauling Exemption? YE NO <br /> 2 <br />