Fresno — CDPH 8668A - Trauma Scene Waste Management Practitioner Application (PDF)

Source: https://www.cdph.ca.gov/CDPH%20Document%20Library/ControlledForms/cdph8668a.pdf

Health and Human Services Agency California Department of Public Health Trauma Scene Waste (TSW) Management Practitioner Application Company Company Name: TSW#: Number of Vehicles used to transport waste: Facility Contact Person: Telephone Number: Email: Owner: Telephone Number: Email: Street Address: City: County: State: Zip Code: Mailing Address: City: State: Zip Code: Web Address: Place of business used for storage of trauma scene waste? Yes No If yes, how many freezers are on site:

Medical Waste Hauler and Facility
Provide medical waste transporter information if utilizing a registered hazardous waste
hauler to transport trauma scene waste to a permitted transfer station (TS) or treatment
facility (TSOST), otherwise leave blank.
Hauler Company Name Phone Address (City/State/ZIP Code)
ID Number

Provide information on the permitted medical waste TS and/or TSOST used or list mail-
back company receiving waste.
TS/TS- Permitted Facility Utilized Facility Address Off-Site Transfer
OST ID or Mail-back Information (City/State/ZIP code) Treatment Station
Yes Yes
Yes Yes
Certification
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.
Authorized Representative: Title:
Signature: Date:

CDPH 8668A (04/2026) Page 1 of 2

Required Documents • A copy of the current year service agreement with hauler(s), transfer station(s),off-site treatment facility(s), or mail-back system invoice. • $200 check (made out to Medical Waste Management Fund) for renewal and initial application fee. Mailing Information Mail the documents and fee to: Or courier to: California Department of Public Health California Department of Public Health Medical Waste Management Program Medical Waste Management Program MS 7405 MS 7405 P.O. Box 997377 1725 23rd Street, Suite 110 Sacramento, CA 95899-7377 Sacramento, CA 95816

CDPH 8668A (04/2026) Page 2 of 2