N.J. DEPT OF ENVIRONMENTAL
DEP USE ONLY
GENERATOR ID NO
APPLICANT ID NO
A . Name of business
B. Name of business
C. Business mailing address:
1. Street address
2. City _____________________County ______________ State _______ ZIP ___________
3. Telephone ________________ Contact person __________________________________
D. Business location (site) address:
1. If same as C above, mark "x" here _____, skip to E below.
2. Street address _____________________________________________________
3. City ___________________ County ______________________ State _________
E. Tax I.D. number _____________________________________________________
F. SIC number ________________________________________________________
G. Do you have more than one business? Yes or No (Circle one)
H. Fee calculation:
1. Projected medical waste generation _________________________________________
2. Generator category number ______________ Fee amount ____________________
3. Enter the date when your site first began generating regulated medical waste: ________________
I. Certification and signature:
1. This is to certify that the information contained in this form is correct and complete to the best of my knowledge.
Name(signature) Date signed
Print or type all information.
Do not write in the section entitled "for official DEP use only."
If a site does not generate regulated medical waste as defined at N.J.A.C. 7:26-3A.6 you are not required to register with this department as a generator of regulated medical waste.
A. Enter the name of the person(s), partnership or corporation that owns the business.
B. Enter the name of the business. Enter the trade name if different than the business name.
C. Enter the mailing address where all correspondence and invoices are to be sent. Enter the name and phone number of the contact person at the mailing address. All phone calls will be made to, and all correspondence will be addressed to, this person's attention.
D. Enter the address of the business where it is physically located. If the street location is the same as the mailing address, mark an "x" in the space indicated and leave the other lines blank.
E. Enter the tax identification number of the business.
F. Standard Industrial Classification(SIC). This system was developed by the federal government to provide a method to define industrial categories in accordance with the composition and structure of the national economy. Please review the Standard Industrial Classification Numbers to determine the SIC number for the business. Select the best match. If none of the SIC codes match the service that your office provides, please select number 8099.
|STANDARD INDUSTRIAL CLASSIFICATION (SIC) NUMBER||NO.|
|Veterinary Services for Animal Specialties||0742|
|Funeral Services and Crematories||7261|
|Doctors of Medicine Offices & Clinics||8011|
|Dentists Offices and Clinics||8021|
|Osteopathy Offices and Clinics||8031|
|Podiatrists Offices and Clinics||8043|
|Health Practitioners Offices & Clinics, not classified elsewhere||8049|
|Skilled Nursing Care Facilities||8051|
|Nursing & Personal Care Facilities, not classified elsewhere||8059|
|General Medical and Surgical Hospitals||8062|
|Specialty Hospitals, except psychiatric||8069|
|Home Health Care Services||8082|
|Kidney Dialysis Centers||8092|
|Specialty Outpatient Facilities, not classified elsewhere||8093|
|Health and Allied Services, not classified elsewhere||8099|
|Elementary and Secondary Schools||8211|
|Colleges, Universities and Professional Schools||8221|
|Research and Development Labs||8731|
|Commercial Testing Labs||8734|
G. If you have more than one business or more than one location for
your business which are not registered, photocopy the Registration and Fee
Submittal Form as many times as needed. You must submit a completed Registration
and Fee Submittal Form for each unregistered site where regulated medical
waste is generated. A site is each noncontiguous
H. FEE TABLE:
|Generator||Pounds of RMW|
|Category||Generated 12er Year per Site||Base Fee|
|1||Less than 50 lbs. per year||$ 85 per site|
|2||50 lbs. to 200 lbs. per year||$255 per site|
|3||201 lbs. to 300 lbs. per year||$500 per site|
|4||301 lbs. to 1000 lbs. per year||$1,000 per site|
|5||More than 1000 lbs. per year||$3,500 per site|
1 . The registration year for generators shall extend from July 22 through
July 21 of each calendar year and fees shall be payable by August 20 of each
calendar year. Enter the projected annual amount of regulated medical waste
in pounds that will be generated at this site during the next twelve months(which
should be your first full year of generating waste) even if you are registering
for a period of less than a full year.
2. Select from H above the appropriate generator category. Enter the correct generator category number. Select from H above the appropriate generator fee amount. If you are registering for a period of less than a full year, enter the correct generator fee amount for a full year. Partial payments are not accepted for a partial year. At the beginning of next years registration period an invoice will be sent to you based on that amount. A space will be provided on that invoice for you to modify, if necessary the amount generated and the fee. Subsequent invoices will be based on the pounds of waste generated in each preceding registration year. Please review and modify each invoice, if necessary before mailing a check. No refunds will be issued after we receive a check.
3. Enter the date when your site first began generating regulated medical waste.
Your fee must be sufficient to pay for the time period beginning with this date.
Enclose a check or money order with the Registration and Fee Submittal Form made payable to "Treasurer, State of New Jersey."
Do not send in a check without a form. To assure that your account is credited, the check must be accompanied by a form.
I. This certification must be signed by a responsible official or selected agent of your business. If you require assistance in completing this form, contact the Medical Waste Registration Unit at (609) 984-3448.
Completed registration forms and fees are to be mailed to the:
BUREAU OF LICENSING & REGISTRATIONS
MAIL CODE 09-01
9 EWING ST., P O BOX 420
TRENTON, NJ 08625-0420
Notify us if your registration information changes.
Make a copy of your completed registration form for your records. If your information on this registration form changes in the future, send a signed letter to us at the address above, on your business letterhead. Notethe old and the new information. Include your generator identification number on all correspondence.?