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 State Zip Code

4. Contact Person: Telephone: ( )

5. Name of Facility Owner:

6. Mailing Address of Facility Owner:

Street City State Zip Code

7. Business Phone: ( ) 24-Hour Emergency Phone: ( )

8. Name of Property Owner:

9. Mailing Address of Property Owner:

Street City State Zip Code

10. Type of Waste Generated: Sharps Non-sharps

11. Method of Removal (Check One): _____1. By applicant, to where:

_____2. By transporter, company name:

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

13. Branch Offices: Yes No If yes, attach sheet with complete name, address and phone number of branch office(s).

Check Type of Facility:

01. Hospital 07. Dentist 13. Surgical Center/Walk-in Clinic
02. Funeral Home 08. Podiatrist 14. Blood Banks
03. Dialysis Clinic 09. Osteopath
04. Nursing Home 10. Home Health 16. Abortion Clinics
05. Veterinarian 11. State Laboratory/Clinic 17. Other (specify)
06. Medical Doctor 12. Clinical Laboratory 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) Date

DH 4089, 12/09
Page 1 of 1
 Alachua Clay Flagler
Department of Health in Alachua, Department of Health in Clay Department of Health in Flagler
Environmental Health Section County, Environmental Health County, Environmental Health
224 SE 24th Street, Gainesville, Section Section
FL 32601 P.O. Box 578, Green Cove P.O. Box 847, Bunnell, FL 32110
(352) 334-7930 Springs, FL 32043 (386) 437-7358
(904) 278-3782
Baker Franklin
See Duval Collier Department of Health in Franklin
Department of Health in Collier County, Environmental Health
Bay County, Environmental Health Section
Department of Health in Bay Section 137 12th Street, Apalachicola, FL
County, Environmental Health 3339 E. Tamiami Trail, Suite 145, 32329
Section Naples, FL 34112 (850) 653-2113
597 West 11th Street, Panama (239) 252-8200
City, FL 32401 Gadsden
(850) 872-4660 Columbia Department of Health in Gadsden
See Alachua County, Environmental Health
Bradford Section
See Alachua Dade (Miami-Dade) Physical Address: 278 LaSalle
Department of Health in Miami- Lefall Drive, Quincy, FL 32353
Brevard Dade County, Environmental Mailing Address: P.O. Box 1000,
Department of Health in Brevard Health Section Quincy, FL 32353
County, Environmental Health 1725 NW 167th Street, Miami (850) 875-7200
Section Gardens, FL 33056
Government Center (305) 623-3500 Gilchrist
2725 Judge Fran Jamison Way, See Alachua
Building A 116, Viera, FL 32940 DeSoto
(321) 633-2100 Department of Health in DeSoto Glades
County, Environmental Health Department of Health in Glades
Broward Section County, Environmental Health
Department of Health in Broward 34 S. Baldwin Avenue, Arcadia, FL Section
County, Environmental Health 34266 1021 Health Park Drive, Moore
Section (863) 993-4601 Haven, FL 33471
2421 SW 6th Avenue, Fort (863) 946-0707, ext. 203
Lauderdale, FL 33315 Dixie
(954) 467-4700 See Alachua Gulf
Department of Health in Gulf
Calhoun Duval County, Environmental Health
Department of Health in Calhoun Duval provides service for: Baker Section
County, Environmental Health & St. Johns County 2475 Garrison Avenue, Port St.
Section Department of Health in Duval Joe, FL 32456
19611 State Road 20 West, County, Environmental Health (850) 227-1276, ext. 125
Blountstown, FL 32424 Section
(850) 674-5645 900 University Boulevard N., Suite Hamilton
300, Jacksonville, FL 32211 See Alachua
Charlotte (904) 253-1785
Department of Health in Charlotte Hardee
County, Environmental Health Escambia See Polk
Section Escambia provides service for:
1100 Loveland Boulevard,Port Okaloosa, Santa Rosa, and Hendry
Charlotte, FL 33980 Walton County Department of Health in Hendry
(941) 624-7200 Department of Health in Escambia County, Environmental Health
County, Environmental Health Section
Citrus Section 1140 Pratt Boulevard, LaBelle, FL
Florida Department of Health in 1300 West Gregory, Pensacola, 33975
Citrus County FL 32501 (863) 674-4047
Environmental Health Section (850) 595-6700, ext. 2052
3600 W Sovereign Path
Lecanto, FL 34461
(352) 527-5295
 Hernando Lafayette Marion
Department of Health in Hernando See Alachua Department of Health in Marion
County, Environmental Health County, Environmental Health
Section Lake Section
7551 Forests Oaks Boulevard, Department of Health in Lake 1801 SE 32nd Avenue, Ocala, FL
Spring Hill, FL 34606 County, Environmental Health 34478
(352) 540-6800 Section (352) 622-7744
Physical Address: 315 W. Main
Highlands Street, Tavares, FL 32778 Martin
Department of Health in Highlands Mailing Address: P.O. Box 1305, Department of Health in Martin
County, Environmental Health Tavares, FL 32778 County, Environmental Health
Section (352) 253-6130 Section
Mailing Address: 7205 South 3441 SE Willoughby Boulevard,
George Boulevard, Sebring, FL Lee Stuart, FL 34994
33875 Department of Health in Lee (772) 221-4090
Physical Address: 501 South County, Environmental Health
Commerce Avenue, Sebring, FL Section Monroe
33870 2295 Victoria Avenue, Fort Myers, Department of Health in Monroe
(863) 402-6550 FL 33901 County, Environmental Health
Section
Hillsborough Leon 102050 Overseas Highway, Suite
Department of Health in Department of Health in Leon 202, Key Largo, FL 33037
Hillsborough County, County, Environmental Health (305) 289-2721
Environmental Health Section Section
P.O. Box 5135, Tampa, FL 33675- 435 N. Macomb Street, Nassau
5135 Tallahassee, FL 32301 Department of Health in Nassau
(813) 307-8015 (850) 606-8350 County, Environmental Health
Section
Holmes Levy P.O. Box 15100, Fernandina
Department of Health in Holmes See Alachua Beach, FL 32035
County, Environmental Health (904) 530-6800
Section Liberty
603 Scenic Circle, Bonifay, FL Department of Health in Liberty Okaloosa
32425 County, Environmental Health See Escambia
(850) 547-8500 Section
12832 NW Central Avenue, Bristol, Okeechobee
Indian River FL 32321 Department of Health in
Department of Health in Indian (850) 643-2415 Okeechobee County,
River County, Environmental Environmental Health Section
Health Section Madison 1728 NW 9th Avenue,
1900 27th Street, Vero Beach, FL Department of Health in Madison Okeechobee, FL 34972
32960-3383 County, Environmental Health
(772) 794-7440 Section Orange
218 SW 3rd Avenue, Madison, FL Department of Health in Orange
Jackson 32340 County, Environmental Health
Department of Health in Jackson (850) 973-5000 Section
County, Environmental Health 1001 Executive Center Drive, Suite
Section Manatee 200, Orlando, FL 32803
4487 Lafayette Street; P.O. Box Department of Health in Manatee (407) 858-1497
310, Marianna, FL 32448 County, Environmental Health
(850) 482-9227 Section Osceola
410 Sixth Avenue, E., Bradenton, Department of Health in Osceola
Jefferson FL 34208 County, Environmental Health
Department of Health in Jefferson (941) 748-0747 Section
County, Environmental Health 1 Courthouse Square, Suite 1200,
Section Kissimmee, FL 34741
1255 West Washington, (407) 742-8600
Monticello, FL 32344
(850) 342-0170
 Palm Beach Seminole
Department of Health in Palm Department of Health in Seminole
Beach County, Environmental County, Environmental Health
Health Section Section
Physical Address: 800 Clematis Physical Address: 1101 E. 1st
Street, West Palm Beach, FL Street, Sanford, FL 32771
33401 Mailing Address: 400 W. Airport
Mailing Address: P.O. Box 29, Boulevard, Sanford, FL 32773
West Palm Beach, FL 33401 (407) 665-3604
(561) 837-5900
Sumter
Pasco Department of Health in Sumter
Department of Health in Pasco County, Environmental Health
County, Environmental Health Section
Section 415 East Noble Avenue, Bushnell,
5640 Main Street, New Port FL 33513
Richey, FL 34652 (352) 569-3131
(727) 841- 4425
Suwannee
Pinellas See Alachua
Department of Health in Pinellas
County, Environmental Health Taylor
Section Department of Health in Taylor
8751 Ulmerton Road, Suite 2000, County, Environmental Health
Largo, FL 33771 Section
(727) 507-4336 1215 N. Peacock Avenue, Perry,
FL 32347
Polk (850) 584-5087, ext. 157
Polk County provides services for:
Hardee County Union
Department of Health in Polk See Alachua
County, Environmental Health
Section Volusia
2090 E. Clower Street, Bartow, FL Department of Health in Volusia
33830 County, Environmental Health
(863) 519-8330, ext. 6 Section
1845 Holsonback Drive, Daytona
Putnam Beach, FL 32117
See Alachua (386) 822-6244

Santa Rosa Wakulla

See Escambia Department of Health in Wakulla
County, Environmental Health
Sarasota Section
Department of Health in Sarasota 48 Oak Street, Crawfordville, FL
County, Environmental Health 32327
Section (850) 888-6099
1001 Sarasota Center Boulevard,
Sarasota, FL 34240 Walton
(941) 861-6133 See Escambia

St. Johns Washington

See Duval Department of Health in
Washington County,
St. Lucie Environmental Health Section
Department of Health in St. Lucie 1338 S. Boulevard, Chipley, FL
County, Environmental Health 32428
Section (850) 638-6240
5150 NW Milner Drive, Port St.
Lucie, FL 34983
(772) 873- 4898