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Limited Quantity Hauling Exemption (LQHE) Check Sheet DHS-8664 - California

Limited Quantity Hauling Exemption (LQHE) Check Sheet Form. This is a California form and can be used in Medical Waste Management Program Department Of Health And Human Services Statewide .
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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 c
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