REGISTRATION FORM - Mississippi Department of ...
May, 2010
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MISSISSIPPI DEPARTMENT OF ENVIRONMENTAL QUALITY
OFFICE OF POLLUTION CONTROL
SOLID WASTE DIVISION
P. O. BOX 2261
JACKSON, MS 39225
REGISTRATION FORM
HOME-GENERATED SHARPS COLLECTION STATION
|Instructions: Type directly into the fields below. When completed, save to your computer. Print a copy of the completed form and mail to |
|the above address or return by email to bill_barnett@deq.state.ms.us. If you are registering multiple locations for one entity (e.g. fire |
|departments, chain pharmacies, etc.), you may attach a typed listing of locations with physical addresses and phone numbers for each |
|location. |
Name of Business or Organization:
Street Address:
City/Town: Zip Code: Phone:
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Name of Person Responsible for Operating the Station:
Mailing Address of Person Above:
(if different from street address)
City/Town: Zip Code:
Check this box only if you wish for this collection station to be excluded from the MDEQ’s published list of sharps collection stations?
THANK YOU FOR REGISTERING AND OPERATING A SHARPS COLLECTION STATION. YOUR EFFORTS TO DO SO REPRESENT A SERVICE TO EVERY PERSON WHO USES SHARPS IN THEIR HOME AND A COMMITMENT TO A SAFER ENVIRONMENT FOR EVERYONE IN YOUR COMMUNITY.
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