Fillable MEDICAL WASTE PROGRAM APPLICATION (Contra Costa Health Services)

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MEDICAL WASTE PROGRAM APPLICATION (Contra Costa Health Services)

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  • 4 check-boxes
  • 38 other fields

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File type: PDF

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CONTRA COSTA
ENVIRONMENTAL HEALTH DIVISION
2120 DIAMOND BOULEVARD, SUITE 100
CONCORD, CA 94520
(925) 608-5500 PHONE | (925) 608-5502 FAX
http://www.cchealth.org/eh
medical.waste@cchealth.org
MEDICAL WASTE PROGRAM APPLICATION
(APPLICATION FEE IS DUE AND NON-REFUNDABLE)
SECTION 1: Type of Application (**Requires a Medical Waste Management Plan)
New Facility** Change of Facility Ownership** Change of Facility Name** Change of Accounts Receivable Info
SECTION 2: Type of Facility (check one):
Med/Dent/Vet Clinic (> 200 lbs./month)
Acute Care Hospital (1-99 beds)
Biomed Producer (> 200 lbs./month)
Med/Dent/Vet Clinic (< 200 lbs./month)
Acute Care Hospital (100-199 beds)
Biomed Producer (< 200 lbs./month)
Med/Dent/Vet Clinic w/ On-site Treatment (>200 lbs./month)
Acute Care Hospital (200-250 beds)
Common Storage Facility (2-10 generators)
Med/Dent/Vet Clinic w/ On-site Treatment (< 200 lbs./month)
Acute Care Hospital (251+ beds)
Common Storage Facility (11-49 generators)
Skilled Nursing Facility (> 200 lbs./month)
Health Care Service Plan
Clinical Laboratory (> 200 lbs./month)
Skilled Nursing Facility (< 200 lbs./month)
Specialty Clinics
SECTION 3: Contact Information
(Owner/Permit Holder Address and Facility Address must be different addresses)
A. Owner / Permit Holder Information (If marking an ownership type, please provide proof)
OWNER / PERMIT HOLDER NAME:
INC
LLC
LP
CORP
CITY / STATE / ZIP CODE :
PHONE # :
FAX # :
B. Facility Information
CITY / STATE / ZIP CODE :
PHONE # :
FAX # :
C. Accounts Receivable Information
CITY / STATE / ZIP CODE :
PHONE # :
FAX # :
SECTION 4: Terms/Signature
Under penalty of law I declare that to the best of my knowledge and belief the information that I have provided is true and accurate. I also agree to conform to all
conditions, orders, and directions issued pursuant to the California Health and Safety Code, Section 117600 – 118360 (The Medical Waste Management Act) and all
applicable local ordinances.
Signature of Applicant: ____________________________________________________ Date: ________________________________________
FOR OFFICE USE ONLY
FA#:
PR#:
AR# :
P/E:
EHS:
RECEIVED BY:
DATE RECEIVED:
AMOUNT DUE:
$
AMOUNT PAID:
$
CHECK #:
METHOD OF PAYMENT:
❑
CASH
❑
❑
CHECK
RECEIPT #:
XR
MED WASTE APP (REV. 2/7/2020)
CREDIT CARD
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MEDICAL WASTE PROGRAM APPLICATION (Contra Costa Health Services)

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Completed 10 January 2021

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