State of California—Health and Human Services Agency California Department of Public Health California Medical Waste Management Program LIMITED QUANTITY HAULING EXEMPTION (LQHE) CHECKLIST This checklist provided for your convenience to help track your application process. Keep it for your records. If your agency/practice is located in a county where the state is the local enforcement agency for medical waste and qualifies for a limited quantity hauling exemption, follow the steps below to insure that all necessary data is provided to the State. Once all documentation is reviewed and verified, an exemption will be sent to you. Medical waste may not be hauled until the California Department of Public Health (Department) or Local Enforcement Agency (LEA) has issued a limited quantity hauling exemption. 1. The point of generation must be within a county or city where the Department is the local enforcement agency. A California map depicting these areas is available on the CDPH website at http://www.cdph.ca.gov. If the Department is not the local enforcement agency, contact your local Environmental Health Office. 2. Complete the application on page 3. 3. For first-time applications, complete a facility registration application (CDPH 8550) as well. This form is necessary to register/list your facility as a new medical waste generator. Your facility must be registered/listed as a “generator” of medical waste with the Department or local Environmental Health Office before an LQHE is granted. 4. Complete a “Need Statement.” See example paragraphs on page 2. 5. Enclose the required fee payment as described on the LQHE application or see the fee page available on the CDPH web site at http://www.cdph.ca.gov. This fee is based on the number of staff who will be transporting the medical waste. 6. Submit a copy of your facility’s consolidation agreement. A consolidation arrangement, other than pick-up by a permitted medical waste transporter (such as deposit for consolidation with another facility not part of your organization), must be verified with a letter of acknowledgement from that facility. Please ensure that this letter includes the full name, address, and telephone number for the facility, as well as the name of a contact person, and submit a copy with your facility’s LQHE application. 7. The LQHE application does not constitute authorization to transport medical waste—it is only an application. Upon approval, a LQHE certificate will be issued with an expiration date one year from the date of approval, the name of the generator, and an identification number issued by the Department. This exemption is void if any of the conditions specified above are violated or exceeded. 8. Receive your facility’s LQHE from the Department or local Environmental Health Office. NOTE: Permitted medical waste transporters/haulers are not LQHEs. Page 1 of 4 CDPH 8664 (07/07) American LegalNet, Inc. www.FormsWorkflow.com Limited Quantity Hauling Exemption “Need Statement” Examples (Please submit on letterhead with signature of the responsible party.) Example 1 (Private Practice): I am a physician with a private practice located at 900 Main Street, Anywhere, CA. My practice generates less than 20 pounds of medical waste per week. Fairview Hospital, 200 Apple Street, Downtown, CA, is an acute care hospital with on-site treatment of medical waste. I am on the staff of this hospital, and this facility will accept the medical waste generated at my practice for treatment. A letter is enclosed from this hospital verifying this affiliation. The Limited Quantity Hauling Exemption is needed to transport medical waste generated at my practice to the hospital for treatment. Example 2 (Home Health): Webster Care is a home health agency located at 300 Gold Avenue, Butte Mountain, CA. This agency operates in Yolo and Yuba counties. The Limited Quantity Hauling Exemption is needed so that our professional staff can transport the medical waste generated during their patient visits in the surrounding communities back to our office in Butte Mountain for consolidation and storage. HTX Inc., 100 First Avenue, Pineland, CA, transports and treats the medical waste generated by our agency. Example 3 (Veterinary Office): Horse Care, Inc. is a veterinary clinic located at 90 South First Street, Weaver, CA. Our facility is a small quantity generator producing less than 20 pounds per week. There are two reasons why our firm requires a Limited Quantity Hauling Exemption. These are as follows: 1. Our firm makes house calls and generates medical waste—mostly sharps, as the result of treatments provided during these visits. The Limited Quantity Hauling Exemption is needed to transport this medical waste back to our office in Weaver for consolidation and storage prior to pick-up by Acme Medical Waste Services, a licensed medical waste hauler OR 2. Our firm transports its medical waste directly to Waste Inc., an off-site treatment facility located at 205 Second Street, Weaver, CA, for treatment and disposal. Page 2 of 4 CDPH 8664 (07/07) American LegalNet, Inc. www.FormsWorkflow.com State of California—Health and Human Services Agency California Department of Public Health California Medical Waste Management Program LIMITED QUANTITY HAULING EXEMPTION (LQHE) APPLICATION AND CONDITIONS This Limited Quantity Hauling Exemption (LQHE) Application applies pursuant to Health and Safety Code (HSC), Division 104, Part 14, Section 118030, if any facility personnel are authorized to transport regulated medical waste from the point of generation to a point of storage or treatment. Your facility must also be registered as a LQG or a SQG. LQHE is obtainable if the following conditions are met: 1. An agency that generates less than 20 pounds of medical waste per week per staff member, each of who transports less than 20 pounds of medical waste at any one time as specified in Section 118030. OR 2. A healthcare professional whose practice generates less than 20 pounds of medical waste per week per staff member, each of who transports less than 20 pounds of medical waste at any one time as specified in Section 118030. AND 3. The practice or agency maintains a tracking document or log sheet with the required contents as specified in Section 118040. (See example.) 4. The generator or a designated staff member of your facility transports the medical waste to a permitted medical waste treatment facility, a permitted transfer station, or another point of consolidation as defined in Sections 118140 or 118145. Home health care facilities may accept medical waste only from their staff members operating under this exemption. 5. A copy of a current LQHE certificate, a staff list, and a tracking document/log sheet, MUST be in the specified employee’s possession while transporting the medical waste. 6. The practice or agency notifies the Department of any changes in the information supplied on this form. 7. The practice or agency completes this form and submits a Need Statement describing the relationship between your facility, the person(s) transporting the waste, and the point of waste consolidation. 8. The practice or agency submits an annual fee along with this application. Annual renewals are billed at the same rates. Limited Quantity Hauling Exemption fees: 1–4 names = $25 5–9 names = $5 additional per name 10 or more names = $50 total fee 9. Consolidation arrangements other than pick-up by a permitted medical waste transporter (such as deposit for consolidation with another facility not part of your organization) must be verified with a letter of acknowledgement from that facility. Please ensure that this letter includes the full name, address, and telephone number for the facility, as well as the name of a contact person, and submit a copy with this application. In order to receive a Limited Quantity Hauling Exemption, complete the following information and return this form with fee payment, Need Statement (see examples on page 2), and other necessary documentation for final approval to the California Department of Public Health, Medical Waste Management Program, P.O. Box 997377, MS 7405, Sacramento, CA 95899 7377. Generator Information (LQG or SQG) Permitted Treatment Facility Name Name Address Address City, State, ZIP code City, State, ZIP code County Telephone number Transporter to treatment facility (if applicable) Fax number Name Telephone number Location of consolidation for pick-up Employees authorized to transport medical waste: 1. 5. 2. 6. 3. 7. 4. 8. (If additional names are to be added, attach separate sheets as needed.) Signature of Generator Date Name of generator (please print or type) Title Page 3 of 4 CDPH 8664 (07/07) American LegalNet, Inc. www.FormsWorkflow.com LIMITED QUANTITY HAULING EXEMPTION (LQHE) EXAMPLE MEDICAL WASTE LOG SHEET (Per California Health and Safety Code Section 118030) To be used by home agencies, private practices, or other professional health care facilities with a Limited Quantity Hauling Exemption (LQHE) approved by a county or state medical waste management program. No more than 20 pounds of medical waste may be transported at any time, and only by staff whose names were submitted along with the LQHE application. Storage of medical waste, except in a designated and/or approved storage area at the place of generation or consolidation, is not allowed under any circumstance. Completed log sheets must be kept on-site for at least three years along with tracking documents from the commercial medical waste transporter. Name of health care agency/private practice Telephone number ( Address (number, street) City ) State Date Signed Out Date Returned for Disposal January 03, 2003 January 07, 2003 Container Type* Signed Out By (e.g., sharps container, biohazardous waste, etc.) Example: One three gallon sharps Dr. Jones ZIP code *Enter one medical waste container per line on this tracking form, as per HSC Section 118030. Page 4 of 4 CDPH 8664 (07/07) American LegalNet, Inc. www.FormsWorkflow.com