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GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS DEPARTMENT OF PLANNING AND NATURAL RESOURCES DIVISION OF ENVIRONMENTAL PROTECTION PHONE: St. Croix: (340) 773-1082, FAX: (340) 773-9310 St. Thomas: (340) 774-3320; FAX (340) 714-9549 ———————————————--------------------———————————————— APPLICATION TO GENERATE & STORE MEDICAL WASTE (Please read instructions carefully) Check one: ⃞ New Permit ⃞ Renewal Permit A facility that generates and/or stores infectious medical waste must obtain a permit from DPNR and abide by the requirements of Title 19, Chapter 56. The initial permit fee is $220.00, and the permit is valid for two years. Permits expire on June 30th at the end of the two-year period. Section I - Facility Name, Address, and Contact Information a. Facility Name: _______________________________________________________________________________________ b. Contact Person: ____________________________________ Telephone: (_____)______________________________ c. Facility Address: _____________________________________________________________________________________ (Provide the physical address where medical waste will be generated and/or stored.) d. Name of Facility Owner: ___________________________________ TAX ID __________________________________ e. Mailing Address of Facility Owner: ______________________________________________________________________ _____________________________________________________________________ f. Business Phone: _(_____)_______________________ 24-hour Emergency Phone: (_____)_____________________ Type of Facility Hospital Podiatrist Abortion Clinic Funeral Home Osteopath Tattoo/Body Piercing Dialysis Home Health Chemotherapy Nursing Home State Laboratory/Clinic Oncology Clinic Veterinarian Clinical Laboratory Other: Medical Doctor Surgical Center/Walk-In Clinic Dentist Blood Bank Describe the general layout and operation of the facility and equipment used for storage. (Attach additional sheets, if necessary.): _______________________________________________________________ _____________________________________________________________________________________________ Section II – Property Owner Information: a. Name of Property Owner: ___________________________________________________________________ b. Mailing Address of Property Owner: __________________________________________________________ __________________________________________________________ Medical Waste Permit Application (Revised May 9, 2014) Section III – Medical Waste Tracking: Waste Generation: Type of Waste Generated Sharps Non Sharps Hypodermic needles Human tissue, surgery specimen Vaccines Syringes Autopsy specimen Animal parts, tissue, or fluids Needles with tubing Pharmaceuticals Contaminated animal bedding Broken glass Chemotherapeutic waste Other: Scissors Isolation waste Razors/ Scalpel Blades Human blood & blood products Pipettes Cultures and stocks Total Amount of Waste, by Weight, in pounds, Generated in a 30-day All infectious medical waste shall be handled within the facility in accordance with the generator’s written medical waste management plan to include contingency measures. Medical waste does not include: a) Paper products, paper towels, materials containing non-fluid blood or other solid waste products that are usually generated by medical facilities and which are not bio-hazardous. b) Household waste, including home-generated medical sharps, radioactive waste and hazardous waste, as defined by 40 CFR Part 261.3. c) Any waste normally generated on a farm or ranch during agricultural, veterinary, or livestock management activities. d) Human secretions or excretions that do not contain fluid blood. Method of Removal: Indicate where medical waste will be taken for treatment or further storage. (Check one): ⃞ By Applicant to off-site facility: Name of Facility: _____________________________________________________________________ Address: ____________________________________________________________________________ (Provide the physical address of the facility where medical waste will be shipped.) ⃞ By off-site transporter: Company Name: _____________________________________________________________________ Address: _____________________________________________________________________________ (Provide the physical address of transporter) Receiving Facility: ____________________________________________________________________ Address: _____________________________________________________________________________ (Provide the physical address of facility to which medical waste will be shipped.) The information contained in this application, which serves as a basis for permitting is, to the best of my knowledge, true and correct. I understand that any misrepresentation of the facts in this application, or failure to comply with sanitary standards, is grounds for denial, administrative fine or revocation of the infectious medical waste permit. ______________________________ _______________________________________ ____________ Signature of Authorized Representative Name of Authorized Representative (Print or type.) Date Do Not Write in This Box FOR OFFICIAL USE ONLY Date Received _________________ Permit No. issued ____________ Date Issued __________________ Receipt No. _______________