Sharps Collection Station Registration Form - Form 4400-195

Use of this form is optional. To register a sharps collection station ("station"), you may submit either this form or a letter containing the same information, as required in Wisconsin medical waste rule (see s. NR 526.09(5), Wis. Adm. Code). Please call your local Department of Natural Resources (DNR) solid waste specialist if you have questions or would like written guidance on how to set up, operate or publicize a station. DNR intends to use personally identifiable information on this form only for administration of the infectious waste management program under chs. 144 and 159. Wis. Stats.

Where is the station located?

Name of Location
County
Address
City
State
Zip
Phone
FID (If known)

Who will run the station? (The person who is the 'operator')

Name
Affiliation
Address
City
State
Zip
Phone

Information

Who can people call for more information?
Name
Phone
e-mail

Owner

Who owns the station?
Name
Affiliation
Address
City
State
Zip
Phone
e-mail

Submitter

Who submitted this registration?
Name
Affiliation
Address
City
State
Zip
Phone
e-mail

Other Information

Are any fees charged to users?
What do the fees cover? (e.g. containers, transportation, disposal)
What URL can people use to find out more?
Is there anything else we should know?

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What is your e-mail address?
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