Pierce County Infectious Waste Managment Permit Application

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Pierce County Infectious Waste Managment Permit Application Powered By Docstoc
					                                                                  Infectious Waste Management
                                                                              Permit Application

Infectious waste management activity (Check all applicable activities):
  ❑ Class 1A Generator                                            ❑ Class II Transporter
    Less than 40 gallons/50 pounds per month                        All licensed transporters of waste (TP)
  ❑ Class 1B Generator                                            ❑ Class III Storage and/or Treatment Facility (S)
    41-100 gallons/50-110 pounds per month                        ❑ Alternate Technology Review Request
  ❑ Class 1C Generator                                              Must Include Supporting Documentation
    More than 100 gallons/110 pounds per month


Facility Name                                                                          Phone
Facility Address                                                           City                           Zip
Assessor-Treasurer’s Parcel Number
Mailing Address (if different)                                             City                           Zip
Infectious Waste Coordinator
Email Address
Owner/Operator
Address (if different)                                                     City                           Zip

Application type:          ❑ New Application: Opening Date
                           ❑ Change of Ownership: Permit Number

Generator type:
  ❑ Acupuncture (A)          ❑ Emergency Services (E)     ❑ Medical (M)                          ❑ Pharmacy (PH)
  ❑ Assisted Living (AL)     ❑ Funeral Home (F)           ❑ Mental Health (MH)                   ❑ Tattoo (T)
  ❑ Clinic (C)               ❑ Hospital (H)               ❑ Naturopathic (NP)                    ❑ Trauma Cleanup (TC)
  ❑ Dental (D)               ❑ Lab (L)                    ❑ Nursing/Rehab (N)
  ❑ Other
Types of infectious waste generated, transported, stored or treated:



Amount of infectious waste generated, transported, stored or treated:
                          Approximately             /month ❑ pounds ❑ gallons

Infectious Waste Treatment Method:
    ❑ Onsite Autoclave                            ❑ Onsite Plaster Encasement
    ❑ Onsite Chemical Treatment                   ❑ Other
    ❑ Approved Outside Contractor: Please provide name:




                                                                 G:\LIBSHARE\SRCPRO\WASTE\PROG\IW\FORMS\IWAPP062013.DOCX Rev 06/13
3629 South D Street MS 1045 Tacoma, WA 98418-6813                                                                   (253) 798-6047
                                                                                 Infectious Waste Management
                                                                                             Permit Application

List names and addresses of any other facilities utilized by the applicant (i.e., offices, clinics, etc.) that generate,
transport, store or treat infectious waste.




List name(s) of other parties sharing same office space.



The undersigned, representing the above-named firm, agrees to follow the Board of Health Resolution 2010-4226
(amendment to Resolution No. 712), Pierce County Ordinance No. 89-54S, and City of Tacoma Ordinance No.
24526 Infectious Waste Regulations, which pertain to the generation, transportation, storage and treatment of
infectious waste in Pierce County.


Signature of authorized representative of above-named firm or managing partner                                                             Date


Address of signer (if different from facility address on front of application)


Return application packet along with appropriate fees to:

                                                  Tacoma-Pierce County Health Department
                                                           Waste Management
                                                       3629 South D Street, MS 1045
                                                         Tacoma, WA 98418-6813

                                Make checks payable to Tacoma-Pierce County Health Department




                                                        Health Department Use Only: Validation




                                                                                 G:\LIBSHARE\SRCPRO\WASTE\PROG\IW\FORMS\IWAPP062013.DOCX Rev 06/13
3629 South D Street MS 1045 Tacoma, WA 98418-6813                                                                                   (253) 798-6047

				
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