Small Quantity Medical Waste Generator Closure Request

Facility Information

This is a closure request only.
For business relocation and ownership change, please ALSO submit a new application.*

Small Quantity Medical Waste Generator Closure Request Form

Please select:

Closure

Business Name

FacilityID# (FA#) or Invoice Number

Type of Business (ex. Dentistry)

Street address

City

State

Zip code

Phone

Email

Reason for Closure (Please describe how the final medical waste was handled.)

Date of Final Closure

What NEW site address will your business be locating to? (if applicable)

For business relocation and ownership change, please ALSO submit a new application.

What new business is taking over this location?

New Owner Information:

New Owner Name

New Owner Cellphone Number

New Owner Email Address

Street address

City

State

Zip code

Billing Information:

Street address

City

State

Zip code

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