ADEM Form 411 "Medical Waste Transportation Permit Application" - Alabama

What Is ADEM Form 411?

This is a legal form that was released by the Alabama Department of Environmental Management - a government authority operating within Alabama. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2009;
  • The latest edition provided by the Alabama Department of Environmental Management;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of ADEM Form 411 by clicking the link below or browse more documents and templates provided by the Alabama Department of Environmental Management.

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Download ADEM Form 411 "Medical Waste Transportation Permit Application" - Alabama

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Medical Waste Transportation
Permit Application
(Print or type and submit in duplicate)
A.
Transporter Identification:
Name of transporter:
Contact person:
Title of contact person:
Mailing address:
City:
State:
Zip Code:
Business address:
City:
State:
Zip Code:
Business telephone number:
(
)
-
Emergency/after hours number:
(
)
-
B.
Permit Application: (Check one)
First Application
Permit renewal: Permit No.
Expiration date of current permit:
/
/
Permit Modification: Provide a narrative description of the modifications sought, listing the
Section(s) of the permit to be modified, and rationale for the request to modify the permit.
C.
Transportation Facilities: Complete the following for the principal transportation facility
identified in Section A. above.
1.
Will this facility repackage medical waste? Yes
No
2.
Will this facility compact medical waste?
Yes
No
3.
Will this facility operate refrigeration devices other than a transport vehicle?
Yes
No
ADEM Form 411 01/09 m4
1
Medical Waste Transportation
Permit Application
(Print or type and submit in duplicate)
A.
Transporter Identification:
Name of transporter:
Contact person:
Title of contact person:
Mailing address:
City:
State:
Zip Code:
Business address:
City:
State:
Zip Code:
Business telephone number:
(
)
-
Emergency/after hours number:
(
)
-
B.
Permit Application: (Check one)
First Application
Permit renewal: Permit No.
Expiration date of current permit:
/
/
Permit Modification: Provide a narrative description of the modifications sought, listing the
Section(s) of the permit to be modified, and rationale for the request to modify the permit.
C.
Transportation Facilities: Complete the following for the principal transportation facility
identified in Section A. above.
1.
Will this facility repackage medical waste? Yes
No
2.
Will this facility compact medical waste?
Yes
No
3.
Will this facility operate refrigeration devices other than a transport vehicle?
Yes
No
ADEM Form 411 01/09 m4
1
D.
Transfer Facilities.
Does this permit application also include transfer facilities?
Yes
No
If Yes, complete the following for each transfer facility to be included.
Transfer Facility Name:
Business address:
City:
State:
____________ Zip Code:
Will this facility repackage medical waste?
Yes
No
Will this facility compact medical waste?
Yes
No
Transfer Facility Name:
Business address:
City:
State:
____________ Zip Code:
Will this facility repackage medical waste?
Yes
No
Will this facility compact medical waste?
Yes
No
Transfer Facility Name:
Business address:
City:
State:
____________ Zip Code:
Will this facility repackage medical waste?
Yes
No
Will this facility compact medical waste?
Yes
No
Transfer Facility Name:
Business address:
City:
State:
____________ Zip Code:
Will this facility repackage medical waste?
Yes
No
Will this facility compact medical waste?
Yes
No
Submit additional sheets as required for the number of transfer facilities included in this application.
ADEM Form 411 01/09 m4
2
E.
Attachments: (The application will not be reviewed unless all attachments are submitted)
1.
Medical Waste Management Plan.
2.
A detailed plan of the facility showing property boundaries, area secured for access
control, vehicle parking areas, buildings and other ancillary facilities.
3.
Vehicle Information (for each vehicle used to transport regulated medical waste):
a.
Make, model, and year for all motorized vehicles.
b.
License number of vehicle and state of registration.
c.
Vehicle Identification Number and state.
d.
Name of registered vehicle owner or operator.
e.
Specify which vehicles are refrigerated?
f.
List of other vehicles (trailers, containers, boxcars, etc) and identification number(s).
F.
Certification: (To be signed by a responsible official)
I certify under penalty of law that this document and all attachments were prepared under my direction or
supervision in accordance with a system designed to assure that qualified personnel properly gather and
evaluate the information submitted. Based on my inquiry of the person or persons who manage the
system, or those persons directly responsible for gathering the information, the information submitted is,
to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are
significant penalties for submitting false information, including the possibility of fine and imprisonment for
knowing violations.
Signature:
Typed name:
Official Title:
Date:
Please submit two copies of each Application and attachments to:
Alabama Department of Environmental Management
(Mailing Address):
(Street Address):
Environmental Services Branch
Environmental Services Branch
Land Division
Land Division
P.O. Box 301463
1400 Coliseum Boulevard
Montgomery, AL 36130-1463
Montgomery, AL 36110-2059
Phone:
334-271-7984
Fax:
334-279-3050
Make all checks payable to the Alabama Department of Environmental Management.
ADEM Form 411 01/09 m4
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