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GOVERNMENT OF THE U.S. VIRGIN ISLANDS DEPARTMENT OF PLANNING & NATURAL RESOURCES DIVISION OF ENVIRONMENTAL PROTECTION Telephone: (340) 773-1082 / 774-3320 Fax: (340) 773-9310 Application for Hazardous Waste Generator and Storage Permit A Hazardous waste generator is required to apply for an annual hazardous waste permit and abide by the requirements of Title 19 Chapter 56 section 1560-501. The initial permit fee is $150.00. Permit expires December 31st of each year. Please submit the completed form to DPNR-DEP. A. General Information 1. Type of facility: Disposal [ ] a) landfill [ ] c) land treatment [ ] b) surface impoundment [ ] d) miscellaneous units [ ] Storage [ ] a) containers [ ] d) tanks [ ] b) piles [ ] e) surface impoundment [ ] c) containment building [ ] f) miscellaneous units [ ] Treatment [ ] a) tanks [ ] d) piles [ ] b) Incineration [ ] e) surface impoundment [ ] c) miscellaneous units [ ] f) boiler/industrial furnace [ ] types of units___________ types of unit _______________ 2. Application for (choose one): ______ New Permit _______Renewal Permit 3. Facility Name: ___________________________________________________________________________________________________ 4. EPA I.D. No. ___________________________________________________________________________________________________ 5. Facility Address:__________________________________________________________________________________________________ Street City State Zip Code 6. Contact Person: _______________________________________________Telephone____(____)_________________________________ 7. Name of Facility Owner: __________________________________________________________________________________________ 8. Mailing Address of Facility Owner:___________________________________________________________________________________ 9. Business Phone: ___(____)_________________________ 24 Hour Emergency Phone: __(___)__________________________________ DPNR use only: Payment Type ____ Check ____Cash Date Received__________________ Receipt No.__________ Permit No._____________________ Date Issued__________ Hazardous Waste Permit 10. Contact person_________________________________________________Telephone___(____)_________________________________ Title____________________________________________________________________________________________________ Mailing Address:__________________________________________________________________________________________ Street City State Zip Code 11. Operator’s Name: _______________________________________________Telephone___(___)_________________________________ 12. Operator’s Address:_______________________________________________________________________________________________ Street City State Zip Code 13. Name of Property Owner: __________________________________________________________________________________________ 14. Mailing Address of Property Owner:__________________________________________________________________________________ Street City State Zip Code 15. Legal structure: [ ] Corporation [ ] Non-profit Corporation [ ] Partnership [ ] Individual [ ] Local Government [ ] State Government [ ] Federal Government [ ] Other 16. If an individual, partnership, or business is operating under an assumed name, specify the district where the name is registered. 17. Method of removal (Check one):_____1. By Applicant, to where: _________________________________________________________ _____2. By transporter, company name:_____________________________________________________ 18. Maximum amount of hazardous waste generated during any 30-day period: _______________lbs. 19. Branch Offices : ____Yes ___No If yes, attach sheet with complete name, address and phone number of branch office(s) Check type of waste generated: 01. Medical Infectious Waste 07. Contaminated Sludge from Sewage or Water Supply Treatment Plant 02. Non-Hazardous Industrial/ Commercial 08. Non-Residential Raw Sewage or Sewage-Contaminated Waste 03. Waste Tires 09. Hazardous Industrial/Commercial (EPA #ID required) 04. Asbestos 10. Contaminated Waste Oil 05. Petroleum Contaminated Soil 11. Low-Level Radioactive Waste 06 Grease Trap Wastes 12. Other The information contained in this application, which serves as a basis for permitting is true and correct. I understand that any misrepresentation of the facts in this application, or failure to comply with sanitary standards, is ground for denial, administrative fine or revocation of the infectious waste permit. Infectious medical waste shall be handled within the facility in accordance with the generator’s written operating plan. ___________________________________________ _______________________________________________ ____________ Signature of Authorized Representative Name of Authorized Representative (print or Type) Date