State of California California Department of Public Health Health and Human Services Agency CDPH 8550 ( 8 /1 8 ) Page 1 of 2 Waste Management Program Generator Registration Application Facility Facility Name: County*: Street Address: City: Zip Code: Mailing Address (if different from above): City: Zip Code: Telephone: Email: *Consult with CDPH prior to applying if you are unsure if CDPH is the enforcement agency for medical waste in your county. Application Type Small Quantity Generator (SQG) Your facility generates less than 200 pounds of medical waste per month. Large Quantity Generator (LQG) Your facility generates 200 pounds or more of medical waste per month. New app Waste Management Plan. Change of ownership : Registration number: Types of waste your facility generate s : b iohazardous sharps pharmaceutical trace chemotherapy pathology Waste Disposal Method Picked up by a registered transporter : Refer to the CDPH h auler page for an updated list of authorized haulers. https://www.cdph.ca.gov/Programs/CEH/DRSEM/Pages/EMB/MedicalWaste/MedicalW aste.aspx Mailed via Mail-Back System: Refer to the CDPH medical waste generators page for mail back information: https://cdph.ca.gov/Programs/CEH/DRSEM/Pages/EMB/MedicalWaste/Generators.aspx Treated onsite by * : By autoclave by the alternative treatment method: * A LQG treating waste onsite shall apply for a permit with Form 8706 . https:// cdph.ca.gov/CDPH%20Document%20Library/ControlledForms/cdph8706.pdf A SQG treating waste onsite (autoclave only) shall register with Form 8705 . https:// cdph.ca.gov/CDPH%20Document%20Library/ControlledForms/cdph8705.pdf American LegalNet, Inc. www.FormsWorkFlow.com CDPH 8550 ( 8 /1 8 ) Page 2 of 2 Certi fication I certify under penalty of perjury that the information contained in this application is true and accurate to the best of my knowledge and belief. Name: Title: Signature: Date: Fees The fee list is available at: https://cdph.ca.gov/CDPH%20Document%20Li brary/ControlledForms/cdph8662.pdf Make the check payable to the Medical Waste Management Fund. Mail the application and fee to: California Department of Public Health Medical Waste Management Program MS 7405 , IMS K - 2 P.O. Box 997377 Sacramento, CA 95899 - 7377 Or courier to: California Department of Public Health Medical Waste Management Program 1 725 23 rd St Suite 110 Sacramento, CA 95816 American LegalNet, Inc. www.FormsWorkFlow.com