Form Dh 4089 PDF Details

In the complex web of healthcare regulation, the management and disposal of biomedical waste stand as critical components, ensuring both environmental safety and public health. The DH 4089 form, emanating from the Florida Department of Health, embodies the structured approach towards the oversight of biomedical waste generation, handling, and disposal within the state. This form is not merely a bureaucratic requirement but a pivotal tool in the application for a Biomedical Waste Generator Permit or its exemption under the specific guidelines of Chapter 64E-16, Florida Administrative Code (F.A.C.). The document delineates a range of specifications from the permit application process, fee structures, to the obligations of currently permitted generators, particularly focusing on those producing less than 25 pounds of biomedical waste in a 30-day period who may qualify for an exemption. With an initial permit fee set at $85.00—and an increased fee for late renewals—this mechanism emphasizes fiscal responsibility alongside regulatory compliance. Furthermore, the form accommodates various healthcare providers including hospitals, clinics, and even tattoo parlors, underlining the broad scope of this regulatory framework. The necessity for applicants to affirm the accuracy of their information under penalty of fines or permit revocation encapsulates the form’s role not only as a procedural step but also as a declaration of adherence to stringent health and safety standards. Designed to cater to the unique needs of a diverse array of biomedical waste generators, the DH 4089 form stands as a testament to Florida's commitment to maintaining high sanitary standards within its healthcare landscapes.

QuestionAnswer
Form NameForm Dh 4089
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesREV4089 application for biomedical waste generator permit 2009 form

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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

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Part # 1 for submitting Form Dh 4089

2. The subsequent stage is usually to fill in these particular blanks: Hospital Funeral Home Dialysis, Maximum weight of biomedical, Surgical CenterWalkin Clinic, Dentist Podiatrist Osteopath, Signature of Authorized, Name of Authorized Representative, Date, and Page of.

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