GOVERNMENT OF THE U.S. VIRGIN ISLANDS
GOVERNMENT OF THE U.S. VIRGIN ISLANDS DEPARTMENT OF PLANNING & NATURAL RESOURCES DIVISION OF ENVIRONMENTAL PROTECTION (340) 773-1082 / 774-3320 Application for Infectious Medical Waste Transporter Registration Infectious medical waste transporters must be permitted by DPNR. The initial permit is $55.00 (vehicle). Each additional vehicle is $10.00. Permits expire on March 31st of each year. The permit fee for the renewal applications received by April 1st is $55.00 (one vehicle). Each additional vehicle is $10.00. The permit fee for renewal applications received after April 1st is $75.00. Each additional vehicle is $10.00. Please submit the completed form to DPNR-DEP. 1. Application for (choose one): ______ New _______Renewal (Applicant must be a legal entity, i.e.: Individual, partnership, corporation, association, or public body) 2. Facility Name: ___________________________________________________________________________________________________ 3. …
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GOVERNMENT OF THE U.S. VIRGIN ISLANDS DEPARTMENT OF PLANNING & NATURAL RESOURCES DIVISION OF ENVIRONMENTAL PROTECTION (340) 773-1082 / 774-3320 Application for Infectious Medical Waste Transporter Registration Infectious medical waste transporters must be permitted by DPNR. The initial permit is $55.00 (vehicle). Each additional vehicle is $10.00. Permits expire on March 31st of each year. The permit fee for the renewal applications received by April 1st is $55.00 (one vehicle). Each additional vehicle is $10.00. The permit fee for renewal applications received after April 1st is $75.00. Each additional vehicle is $10.00. Please submit the completed form to DPNR-DEP. 1. Application for (choose one): ______ New _______Renewal (Applicant must be a legal entity, i.e.: Individual, partnership, corporation, association, or public body) 2. Facility Name: ___________________________________________________________________________________________________ 3. Facility Address:__________________________________________________________________________________________________ Street City State Zip Code 4. Contact Person: _______________________________________________Telephone____(____)_________________________________ 5. Name of Facility Owner: __________________________________________________________________________________________ 6. Mailing Address of Facility Owner:___________________________________________________________________________________ 7. Business Phone: ___(____)_________________________ 8. 24 Hour Emergency Phone: __(___)__________________________________ 9. Name of Property Owner: __________________________________________________________________________________________ 10. Mailing Address of Property Owner:__________________________________________________________________________________ Street City State Zip Code 11. FEDERAL employer Identification Number of transporter: ________________________________________________________________ 12. Anticipated districts to be served: ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ 13. List all known facilities where you will be taking infectious medical waste or further storage (attach additional sheets if necessary): STORAGE TREATMENT DPNR use only: Payment Type ____ Check ____Cash Date Received__________________ Receipt No.__________ Permit No._____________________ Date Issued__________ 14. Number of transport vehicles to be used:______________ 15. Please submit the following information for each transport vehicle you wish to register (attach additional sheets, if necessary): YEAR MAKE MODEL TAG NUMBER VEHICLE IDENTIFICATION NUMBER 16. For renewals only: Please attach copy of Manifest for Infectious Medical Waste transported in the last year. 17. CERTIFICATION: I certify that, to the best of my knowledge and belief, the information provided in this application is true and accurate. ___________________________________________ _______________________________________________ ____________ Signature of Authorized Representative Name of Authorized Representative (print or Type) Date