Form CDPH 8007 Transfer Station and Treatment Facility Disclosure Statement - California

Form CDPH8007 is a California Department of Public Health form also known as the "Transfer Station And Treatment Facility Disclosure Statement". The latest edition of the form was released in June 1, 2018 and is available for digital filing.

Download an up-to-date Form CDPH8007 in PDF-format down below or look it up on the California Department of Public Health Forms website.

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State of California—Health and Human Services Agency
California Department of Public Health
Transfer Station and Treatment Facility Disclosure Statement
Section I: Cover Page
Filling Status:
Facility
Business Type (check only one):
Corporation
General Partnership
Sole Proprietor
Limited Liability Company
Filing with SEC Exemption?
Yes
No
Exempt from fingerprint Requirement?
Yes
No
Applicant Legal Name & Previous Name(s):
Registration No.
Federal Employer ID No.
Street Address (No PO Box):
City:
State:
Zip Code:
Business Phone Number:
Business Fax Number:
E-mail Address:
Mailing Address (If different from Business Address, P.O. Box is Acceptable)
City:
State:
Zip Code:
Is the applicant required to submit a Disclosure Statement for medical waste facility Permit?
Yes
No
If the answer is "Yes," was a Disclosure Statement submitted?
Yes
No
If "Yes," when was the Disclosure Statement submitted? Month:
Year:
List the name on the Disclosure Statement:
If you have filed a Disclosure Statement within the last two years or have filed a Disclosure
Statement for a medical waste facilities permit, complete this page, Section V: Declaration
only, and submit the Disclosure Statement to:
California Department of Public Health
Medical Waste Management Program
MS 7405, IMS K-2
P.O. Box 997377
Sacramento, CA 95899-7377
CDPH 8007 (6/18)
Page 1 of 17
State of California—Health and Human Services Agency
California Department of Public Health
Transfer Station and Treatment Facility Disclosure Statement
Section I: Cover Page
Filling Status:
Facility
Business Type (check only one):
Corporation
General Partnership
Sole Proprietor
Limited Liability Company
Filing with SEC Exemption?
Yes
No
Exempt from fingerprint Requirement?
Yes
No
Applicant Legal Name & Previous Name(s):
Registration No.
Federal Employer ID No.
Street Address (No PO Box):
City:
State:
Zip Code:
Business Phone Number:
Business Fax Number:
E-mail Address:
Mailing Address (If different from Business Address, P.O. Box is Acceptable)
City:
State:
Zip Code:
Is the applicant required to submit a Disclosure Statement for medical waste facility Permit?
Yes
No
If the answer is "Yes," was a Disclosure Statement submitted?
Yes
No
If "Yes," when was the Disclosure Statement submitted? Month:
Year:
List the name on the Disclosure Statement:
If you have filed a Disclosure Statement within the last two years or have filed a Disclosure
Statement for a medical waste facilities permit, complete this page, Section V: Declaration
only, and submit the Disclosure Statement to:
California Department of Public Health
Medical Waste Management Program
MS 7405, IMS K-2
P.O. Box 997377
Sacramento, CA 95899-7377
CDPH 8007 (6/18)
Page 1 of 17
Applicant Legal Name & Previous Name(s):
Registration No.
Federal Employer ID No.
Section II: Facility Identification
Provide the EPA ID number(s) for the business entity. Identify the name associated with each EPA ID
Number. Identify the type of facility in the applicable box.
EPA ID #
Name
Type
Facility
Transporter
Generator
Facility
Transporter
Generator
Facility
Transporter
Generator
Facility
Transporter
Generator
Facility
Transporter
Generator
Facility
Transporter
Generator
Facility
Transporter
Generator
Facility
Transporter
Generator
Facility
Transporter
Generator
Facility
Transporter
Generator
Facility
Transporter
Generator
Facility
Transporter
Generator
Facility
Transporter
Generator
Facility
Transporter
Generator
Facility
Transporter
Generator
Facility
Transporter
Generator
Facility
Transporter
Generator
Facility
Transporter
Generator
Attach as many copies of this sheet as necessary. Provide a separate sheet for each individual or
entity identified in Sections I and II.
CDPH 8007 (6/18)
Page 2 of 17
Applicant Legal Name & Previous Name(s):
Registration No.
Federal Employer ID No.
Section III: Business Entity Disclosure
Identify all partners, members, officers, directors, managers, trustees, controlling persons, or any
person holding more than 5% equity or debt liability in the business entity. For transporters, you must
submit a photocopy of a valid driver license for each person listed below.
*See Information Practices Notice, Page 2 of the Disclosure Statement Instructions for information
related to the disclosure of personal and confidential information.
Name________________________________
Title_______________ %Ownership____________
SSN________________________________ Driver License #______________ Issuing State_____
Name________________________________
Title_______________ %Ownership____________
SSN________________________________ Driver License #______________ Issuing State_____
Name________________________________
Title_______________ %Ownership____________
SSN________________________________ Driver License #______________ Issuing State_____
Name________________________________
Title_______________ %Ownership____________
SSN________________________________ Driver License #______________ Issuing State_____
Name________________________________
Title_______________ %Ownership____________
SSN________________________________ Driver License #______________ Issuing State_____
Name________________________________
Title_______________ %Ownership____________
SSN________________________________ Driver License #______________ Issuing State_____
If additional space is needed, attach as many copies of this sheet as necessary.
List all fictitious (DBA) names that the business currently operates under: (add additional pages as
necessary):
Has the business ever operated under another name(s)?
Yes
No
If yes, list the name(s) here: (Add additional pages as necessary)
Applicant Legal Name & Previous Name(s):
Registration No.
Federal Employer ID No.
CDPH 8007 (6/18)
Page 3 of 17
Applicant Legal Name & Previous Name(s):
Registration No.
Federal Employer ID No.
Section IV: Background Information
Please read the following questions very carefully and answer every question.
Business History Questions
Answer
Has the business entity or any of its partners, members, controlling persons, officers, directors,
managers, trustees, or any person holding more than 5% equity or debt liability in the business
Yes
entity ever been convicted of committing a crime within the last five years?
No
a
A conviction for the purposes of this disclosure statement includes
plea of guilty or nolo
a
contendere, or
verdict or finding of guilt, regardless of whether sentence is imposed by the courts.
a
You do not have to disclose arrests that did not result in
conviction and for which you are not
awaiting final adjudication; any arrest, conviction or other proceeding the record of which has been
a
sealed or destroyed by order of
court.
If you answer Yes, you must include ATTACHMENT 1- Record of Criminal Cases (making as many
copies as necessary) for each conviction.
Has the business entity or any of its partners, members, controlling persons, officers, directors,
managers, trustees, or any person holding more than 5% equity or debt liability in the business
Yes
entity ever been involved in a civil proceeding regarding any violation of or non-compliance with the
No
California Health and Safety Code, Water Code, Vehicle Code, RCRA (42 USC section 6901 et
seq.), HMTA (49 USC section 1801 et seq.), CERCLA (42 USC section 9601 et seq.), TSCA (15
USC section 2601 et seq.) or any other equivalent state or federal statute or any requirement or
regulation adopted pursuant and relating to the generation, transportation, treatment, storage,
recycling, disposal or handling of a medical waste, medical substance or medical material within
the last five years?
a
A civil proceeding for the purposes of this disclosure statement includes any civil action filed in
a
court of law, regardless of whether
judgment is issued by the courts.
If you answer Yes, you must include ATTACHMENT 2- Record of Civil Cases (making as many
copies as necessary) for each civil proceeding.
Has the business entity or any of its partners, members, controlling persons, officers, directors,
managers, trustees, or any person holding more than 5% equity or debt liability in the business
Yes
entity ever been involved in an administrative proceeding regarding any violation of or non-
No
compliance with the California Health and Safety Code, Water Code, Vehicle Code, RCRA (42
USC section 6901 et seq.), HMTA (49 USC section 1801 et seq.), CERCLA (42 USC section 9601
et seq.), TSCA (15 USC section 2601 et seq.) or any other equivalent state or federal statute or any
requirement or regulation adopted pursuant and relating to the generation, transportation,
treatment, storage, recycling, disposal or handling of a medical waste, medical substance or
medical material within the last five years?
An administrative action for the purposes of this disclosure statement includes any action taken by
a
a regulatory agency regardless of whether
hearing was held. Administrative actions include
administrative orders issued by local, state and federal regulatory agencies.
If you answer Yes, you must include ATTACHMENT 3- Record of Administrative Actions (making
as many copies as necessary) for each administrative action.
CDPH 8007 (6/18)
Page 4 of 17
Applicant Legal Name & Previous Name(s):
Registration No.
Federal Employer ID No.
Business History Questions (continued)
Answer
Has the business entity or any of its partners, members, controlling persons, officers, directors,
managers, trustees, or any person holding more than 5% equity or debt liability in the business
Yes
entity ever had a license, permit, registration or certificate suspended, revoked or denied relating to
No
the generation, transportation, treatment, storage, recycling, disposal or handling of a medical
waste, medical substance or medical material by a local, state, or federal regulatory agency within
the last five years?
A license, permit, registration, or certificate for the purposes of this disclosure statement includes
a
any authority or privilege granted by
federal, state or local regulatory agency.
If you answer Yes, you must include ATTACHMENT 3- Record of Administrative Actions (making
as many copies as necessary) for each administrative action.
Has the business entity or any of its partners, members, controlling persons, officers, directors,
managers, trustees, or any person holding more than 5% equity or debt liability in the business
Yes
entity held or applied for a license, permit, registration or certificate relating to the generation,
No
transportation, treatment, storage, recycling, disposal or handling of a medical waste, medical
substance or medical material by a local, state, or federal regulatory agency within the last five
years? .
A license, permit, registration, or certificate for the purposes of this disclosure statement includes
a
any authority or privilege granted by
federal, state or local regulatory agency.
If you answer Yes, you must include ATTACHMENT 4- Record of Permits, Licenses and
Registrations (making as many copies as necessary).
Are there any agencies outside of the state of California who regulate, or who have regulated the
business entity in the generation, treatment, storage, recycling, disposal, or handling of medical
Yes
waste or medical material, within the last five years?
No
If you answer Yes, you must include ATTACHMENT 5- Record of Regulatory Agencies (making as
many copies as necessary.
CDPH 8007 (6/18)
Page 5 of 17

Download Form CDPH 8007 Transfer Station and Treatment Facility Disclosure Statement - California

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