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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