IW-04 Infectious Medical Waste Transport Vehicle Application - DHHR by fjzhangweiyun


									IW-04                           West Virginia Department of Health and Human Resources
9/05                                      Office of Environmental Health Services
                                             Infectious Medical Waste Program

                                        Transportation Vehicle Permit Application

Application for a            New                Renewal permit.
Applicant                                                                  Associates
SS# (not required for corporations or government entities)                                   FEIN
Business Name
Other Names Under Which You Operate

                                                Local                                                     Headquarters
Fax No.
Spill Contact Person                                              Telephone                           Fax No.

Vehicles:                  #1                                   #2                                   #3
Lic. No. (State)
Vin No.
Current Permit No.         IMW-99-                                IMW-99-                             IMW-99-

Treatment Facilities:
                           #1                                   #2                                   #3
Phone No.
State Permit Number

Counties and Cities served in West Virginia:

         I hereby certify that all employees involved in the transportation of infectious medical wastes have received training in the
proper handling of infectious medical waste and spill cleanup techniques. I further certify that I have reviewed the transportation
requirements in the Legislative Rule (64-56-9) and will comply with the same.

           Date of Application                                                                          Signature of Applicant
                                                                                                       ( ) Owner ( ) Agent
Checks should be made payable to the WV Bureau for Public Health. Mail completed application and fee of $250.00 per vehicle to:
                Office of Environmental Health Services - Infectious Medical Waste Program
                Capitol & Washington Streets
                1 Davis Square, Suite 200
                Charleston, WV 25301-1798                   Telephone No. (304) 558-6725, Fax No. (304) 558-0524

                                                      For Department Use Only
Date application with fee received                                                         Amount paid $
Date reviewed by                                                                           Check number
Date approved by                                                                           Date of check
Date denied by                                 (attach denial letter)                      Application No.
Date issued                                                                                FEIN check
Date expires                                           Permit number IMW-99-

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