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PRE-APPLICATION QUESTIONNAME <br /> Please check the appropriate response for the questions listed below. <br /> MEDICALREGULATED <br /> (xjLaboratory Wastes-specimen or microbiologic cultures, stocks of infectious agents, <br /> live and attenuated vaccines, and culture mediums <br /> (x) Blood or Body Fluids - liquid blood elements or other regulated body fluids, or <br /> articles contaminated blood or body fluids <br /> (X) s - syringes, needles, blades, broken glass <br /> OContaminated Animals - animal carcasses, body parts, bedding materials <br /> Surgical - human or animal parts or tissues removed surgically or by <br /> autopsy <br /> OIsolation Wastes - waste contaminated excretion, exudate, or secretions from <br /> humans oranimals a are isolated due only to the highly communicable diseases <br /> listed by Centersfor Disease Control as requiring Biosafety Level 4 precautions.* <br /> . Does your business or service generate any o <br /> e medical wastes listed above? yes xno— <br /> If <br /> your answer is no, please complete the "Certification Stat t" on Page <br /> 5 and return it with this questionnaire to the address indicated. You do not <br /> need to complete the remainder of this questionnaire. <br /> If youranswer is yes ,please check a es(s) of waste listed above that <br /> you or your facility enerte. Please complete the rest of this questionnaire. <br /> . Do you generate less than 200 pounds of medical <br /> waste permonth? if yes, you are a small <br /> generator. yes_;;,,o X <br /> . Small generators may store their medical waste <br /> in a permittedcommon storage facility with <br /> other small generators. Do you plan to do this <br /> at your facility? yes—no— <br /> If o r is M a PHS-EHD "Common Storage Facility Perm°t <br /> Applicatiod' e mailed to you. Please indicate if you want the <br /> application mailed elsewhere. <br /> -CONTINUEDREVERSE- <br />