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` s " a PRE-APPLICATION QUESTIONNAIRE Regulated Medical Wastes Please check the appropriate box for the questions listed below: ❑ Laboratory Wastes: specimen or microbiologic cultures, stocks of infectious agents, live and attenuated vaccines and culture mediums. ❑ Blood or Body Fluids: liquid blood elements, other regulated body fluids, articles contaminated with blood or body fluids. ❑ Sharps: syringes,needles,blades and contaminated broken glass. ❑ Contaminated Animals: animal carcasses,body parts and bedding materials. ❑ Surgical Specimens: human or animal parts or tissues removed surgically or by autopsy. ❑ Isolation Wastes: waste contaminated with excretion, exudates, or secretions from humans or animals who are isolated due only to the highly communicable diseases listed by the Centers for Disease Control as requiring Biosafety Level IV precautions. 1. Does your business or service generate any of the medical waste listed above? Yes❑No If your answer is"No",please complete the "Certification Statement" on Page 4 and return it with this questionnaire to the address indicated. You do not need to complete the remainder of this questionnaire. 2. Do you generate less than 200 pounds of medical waste per month? ❑ Yes❑No If you answered"Yes",you are a small generator. 3. Small generators may store their medical waste in a permitted Common Storage Facility with other small generators. Do you plan to do this at your facility? ❑ Yes 14 No If your answer is"Yes",you must obtain a"Common Storage Facility Permit" from this office. 4. Do you plan to treat your medical waste onsite(at your facility),by autoclaving, incinerating or using microwave technology? ❑ Yes D9 No If you are a small generator and your answers to question 3 &4 are"No",then complete the "Certification Statement" on Page 3 and return it with this questionnaire to the letterhead address. You do not need to complete the rest of this package. If your answer to this question is"Yes",you must complete Pages 4 & 5 and return them with this questionnaire and the appropriate fee to the address indicated on Page 1. 5. If you generate less than 20 pounds of medical waste per week,transport less than 20 pounds at one time, and have a hauling information document on file in your office, you may apply for a Limited Quantity Hauling Exemption from this office. This exemption allows you or your staff to transport medical waste to a medical waste treatment facility. Do you want to apply for a Limited Quantity Hauling Exemption? E] Yes No EHD 45-02-003 Page 2 of 7 1.14-1