Department of Health

DH use only: Check No. _______ Check Amount _______________

Date Received _______________ Receipt No. ___________________

Permit No. ___________________ Date Issued ___________________

Department of Health

Application for Biomedical Waste Generator Permit/Exemption

A biomedical waste generator is required to apply for an annual biomedical waste permit and abide by the requirements of Chapter 64E-16, Florida

Administrative Code (F.A.C.). The initial permit fee is $85.00. Permits expire September 30 of each year. The permit fee for renewal applications

received by October 1 is $85.00. The permit fee for renewal applications received after October 1 is $105.00. State-owned and operated facilities are

exempt from the permit fee. Submit the following information on this form to your local Department of Health Biomedical Waste Coordinator.

FOR CURRENTLY PERMITTED GENERATORS ONLY: A currently permitted biomedical waste generator, that produces less than 25 pounds of

biomedical waste in each 30 day period, may claim an exemption from the fee and permitting requirements only of Chapter 64E-16, F.A.C. A

currently permitted biomedical waste generator applying for exemption from permitting must submit documentation from the previous 12

months showing the biomedical waste generated in each 30 day period during those 12 months was less than 25 lbs. Documentation must

include the amount of waste generated in each 30 day period for the previous 12 months and may be in the form of a monthly log or receipts.

1. Application for (choose one):

Permit

Exemption (attach appropriate documentation)

(Applicant must be a legal entity, i.e.: individual, partnership, corporation, association, or public body)

2. Facility Name:

3. Facility Address:

Street

City

4. Contact Person:

Telephone:

State

(

Zip Code

)

5. Name of Facility Owner:

6. Mailing Address of Facility Owner:

Street

7. Business Phone:

(

City

)

State

24-Hour Emergency Phone:

(

Zip Code

)

8. Name of Property Owner:

9. Mailing Address of Property Owner:

Street

10. Type of Waste Generated:

City

Sharps

11. Method of Removal (Check One):

State

Zip Code

Non-sharps

_____1. By applicant, to where:

_____2. By transporter, company name:

12. Maximum weight of biomedical waste generated during any 30-day period:

13. Branch Offices:

Yes

No

Check Type of Facility:

01. Hospital

02. Funeral Home

03. Dialysis Clinic

04. Nursing Home

05. Veterinarian

06. Medical Doctor

lbs.

If yes, attach sheet with complete name, address and phone number of branch office(s).

07.

08.

09.

10.

11.

12.

Dentist

Podiatrist

Osteopath

Home Health

State Laboratory/Clinic

Clinical Laboratory

13. Surgical Center/Walk-in Clinic

14. Blood Banks

16. Abortion Clinics

17. Other (specify)

18. Tattoo/Body Piercing

The undersigned owner/owner¡¯s representative hereby agrees to operate the biomedical waste generating facility described in this application in

accordance with the requirements of Section 381.0098, Florida Statutes, and Chapter 64E-16, F.A.C. The information contained in this application,

which serves as a basis for permitting or exemption, is true and correct. I understand that any misrepresentation of the facts in this application, or

failure to comply with sanitary standards, is grounds for denial, administrative fine or revocation of the biomedical waste permit or exemption.

Biomedical waste shall be handled within the facility in accordance with the generator¡¯s written operating plan. Operating plan must be in compliance

with 64E-16, F.A.C.

Signature of Authorized Representative

Name of Authorized Representative (print or type)

DH 4089, 12/09

Page 1 of 1

Date

Alachua

Department of Health in Alachua,

Environmental Health Section

224 SE 24th Street, Gainesville,

FL 32601

(352) 334-7930

Baker

See Duval

Bay

Department of Health in Bay

County, Environmental Health

Section

597 West 11th Street, Panama

City, FL 32401

(850) 872-4660

Bradford

See Alachua

Brevard

Department of Health in Brevard

County, Environmental Health

Section

Government Center

2725 Judge Fran Jamison Way,

Building A 116, Viera, FL 32940

(321) 633-2100

Broward

Department of Health in Broward

County, Environmental Health

Section

2421 SW 6th Avenue, Fort

Lauderdale, FL 33315

(954) 467-4700

Calhoun

Department of Health in Calhoun

County, Environmental Health

Section

19611 State Road 20 West,

Blountstown, FL 32424

(850) 674-5645

Charlotte

Department of Health in Charlotte

County, Environmental Health

Section

1100 Loveland Boulevard,Port

Charlotte, FL 33980

(941) 624-7200

Citrus

Florida Department of Health in

Citrus County

Environmental Health Section

3600 W Sovereign Path

Lecanto, FL 34461

(352) 527-5295

Clay

Department of Health in Clay

County, Environmental Health

Section

P.O. Box 578, Green Cove

Springs, FL 32043

(904) 278-3782

Collier

Department of Health in Collier

County, Environmental Health

Section

3339 E. Tamiami Trail, Suite 145,

Naples, FL 34112

(239) 252-8200

Columbia

See Alachua

Dade (Miami-Dade)

Department of Health in MiamiDade County, Environmental

Health Section

1725 NW 167th Street, Miami

Gardens, FL 33056

(305) 623-3500

DeSoto

Department of Health in DeSoto

County, Environmental Health

Section

34 S. Baldwin Avenue, Arcadia, FL

34266

(863) 993-4601

Dixie

See Alachua

Duval

Duval provides service for: Baker

& St. Johns County

Department of Health in Duval

County, Environmental Health

Section

900 University Boulevard N., Suite

300, Jacksonville, FL 32211

(904) 253-1785

Escambia

Escambia provides service for:

Okaloosa, Santa Rosa, and

Walton County

Department of Health in Escambia

County, Environmental Health

Section

1300 West Gregory, Pensacola,

FL 32501

(850) 595-6700, ext. 2052

Flagler

Department of Health in Flagler

County, Environmental Health

Section

P.O. Box 847, Bunnell, FL 32110

(386) 437-7358

Franklin

Department of Health in Franklin

County, Environmental Health

Section

137 12th Street, Apalachicola, FL

32329

(850) 653-2113

Gadsden

Department of Health in Gadsden

County, Environmental Health

Section

Physical Address: 278 LaSalle

Lefall Drive, Quincy, FL 32353

Mailing Address: P.O. Box 1000,

Quincy, FL 32353

(850) 875-7200

Gilchrist

See Alachua

Glades

Department of Health in Glades

County, Environmental Health

Section

1021 Health Park Drive, Moore

Haven, FL 33471

(863) 946-0707, ext. 203

Gulf

Department of Health in Gulf

County, Environmental Health

Section

2475 Garrison Avenue, Port St.

Joe, FL 32456

(850) 227-1276, ext. 125

Hamilton

See Alachua

Hardee

See Polk

Hendry

Department of Health in Hendry

County, Environmental Health

Section

1140 Pratt Boulevard, LaBelle, FL

33975

(863) 674-4047

Hernando

Department of Health in Hernando

County, Environmental Health

Section

7551 Forests Oaks Boulevard,

Spring Hill, FL 34606

(352) 540-6800

Lafayette

See Alachua

Lake

Department of Health in Lake

County, Environmental Health

Section

Physical Address: 315 W. Main

Street, Tavares, FL 32778

Mailing Address: P.O. Box 1305,

Tavares, FL 32778

(352) 253-6130

Highlands

Department of Health in Highlands

County, Environmental Health

Section

Mailing Address: 7205 South

George Boulevard, Sebring, FL

33875

Physical Address: 501 South

Commerce Avenue, Sebring, FL

33870

(863) 402-6550

Lee

Department of Health in Lee

County, Environmental Health

Section

2295 Victoria Avenue, Fort Myers,

FL 33901

Hillsborough

Department of Health in

Hillsborough County,

Environmental Health Section

P.O. Box 5135, Tampa, FL 336755135

(813) 307-8015

Leon

Department of Health in Leon

County, Environmental Health

Section

435 N. Macomb Street,

Tallahassee, FL 32301

(850) 606-8350

Holmes

Department of Health in Holmes

County, Environmental Health

Section

603 Scenic Circle, Bonifay, FL

32425

(850) 547-8500

Levy

See Alachua

Indian River

Department of Health in Indian

River County, Environmental

Health Section

1900 27th Street, Vero Beach, FL

32960-3383

(772) 794-7440

Jackson

Department of Health in Jackson

County, Environmental Health

Section

4487 Lafayette Street; P.O. Box

310, Marianna, FL 32448

(850) 482-9227

Jefferson

Department of Health in Jefferson

County, Environmental Health

Section

1255 West Washington,

Monticello, FL 32344

(850) 342-0170

Liberty

Department of Health in Liberty

County, Environmental Health

Section

12832 NW Central Avenue, Bristol,

FL 32321

(850) 643-2415

Madison

Department of Health in Madison

County, Environmental Health

Section

218 SW 3rd Avenue, Madison, FL

32340

(850) 973-5000

Manatee

Department of Health in Manatee

County, Environmental Health

Section

410 Sixth Avenue, E., Bradenton,

FL 34208

(941) 748-0747

Marion

Department of Health in Marion

County, Environmental Health

Section

1801 SE 32nd Avenue, Ocala, FL

34478

(352) 622-7744

Martin

Department of Health in Martin

County, Environmental Health

Section

3441 SE Willoughby Boulevard,

Stuart, FL 34994

(772) 221-4090

Monroe

Department of Health in Monroe

County, Environmental Health

Section

102050 Overseas Highway, Suite

202, Key Largo, FL 33037

(305) 289-2721

Nassau

Department of Health in Nassau

County, Environmental Health

Section

P.O. Box 15100, Fernandina

Beach, FL 32035

(904) 530-6800

Okaloosa

See Escambia

Okeechobee

Department of Health in

Okeechobee County,

Environmental Health Section

1728 NW 9th Avenue,

Okeechobee, FL 34972

Orange

Department of Health in Orange

County, Environmental Health

Section

1001 Executive Center Drive, Suite

200, Orlando, FL 32803

(407) 858-1497

Osceola

Department of Health in Osceola

County, Environmental Health

Section

1 Courthouse Square, Suite 1200,

Kissimmee, FL 34741

(407) 742-8600

Palm Beach

Department of Health in Palm

Beach County, Environmental

Health Section

Physical Address: 800 Clematis

Street, West Palm Beach, FL

33401

Mailing Address: P.O. Box 29,

West Palm Beach, FL 33401

(561) 837-5900

Pasco

Department of Health in Pasco

County, Environmental Health

Section

5640 Main Street, New Port

Richey, FL 34652

(727) 841- 4425

Pinellas

Department of Health in Pinellas

County, Environmental Health

Section

8751 Ulmerton Road, Suite 2000,

Largo, FL 33771

(727) 507-4336

Polk

Polk County provides services for:

Hardee County

Department of Health in Polk

County, Environmental Health

Section

2090 E. Clower Street, Bartow, FL

33830

(863) 519-8330, ext. 6

Putnam

See Alachua

Santa Rosa

See Escambia

Sarasota

Department of Health in Sarasota

County, Environmental Health

Section

1001 Sarasota Center Boulevard,

Sarasota, FL 34240

(941) 861-6133

St. Johns

See Duval

St. Lucie

Department of Health in St. Lucie

County, Environmental Health

Section

5150 NW Milner Drive, Port St.

Lucie, FL 34983

(772) 873- 4898

Seminole

Department of Health in Seminole

County, Environmental Health

Section

Physical Address: 1101 E. 1st

Street, Sanford, FL 32771

Mailing Address: 400 W. Airport

Boulevard, Sanford, FL 32773

(407) 665-3604

Sumter

Department of Health in Sumter

County, Environmental Health

Section

415 East Noble Avenue, Bushnell,

FL 33513

(352) 569-3131

Suwannee

See Alachua

Taylor

Department of Health in Taylor

County, Environmental Health

Section

1215 N. Peacock Avenue, Perry,

FL 32347

(850) 584-5087, ext. 157

Union

See Alachua

Volusia

Department of Health in Volusia

County, Environmental Health

Section

1845 Holsonback Drive, Daytona

Beach, FL 32117

(386) 822-6244

Wakulla

Department of Health in Wakulla

County, Environmental Health

Section

48 Oak Street, Crawfordville, FL

32327

(850) 888-6099

Walton

See Escambia

Washington

Department of Health in

Washington County,

Environmental Health Section

1338 S. Boulevard, Chipley, FL

32428

(850) 638-6240

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