Laserfiche WebLink
u IN SAN JOA UIN COUNTY <br /> y <br /> ENO ONMENTAL HEALTH DEPARTA 7 <br /> 304 East Weber Avenue, 3`d Floor, Stockton,CA 95202-2708 <br /> `P • (209)46w. ww.co.san-joaqum.ca.us/ehd•Fax:(209)468-3433 ® Web: ww.co.sanjoaqum.ca.us/ehd S 4 19a <br /> 9 L 1 F O Rti Al�/J� <br /> APPLICATION FOR A LIMITE ANTITY HAULING EXEMPT Tti o0/,VC0tj $ <br /> FpqRNTq� tY <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management Act",the loving . <br /> conditions must be met: <br /> The generator or health care professional generates less than 20 pounds of medical waste per week,transport less <br /> than 20 pounds of medical waste at any one time,maintains a tracking document pursuant to Chapter 6 and the <br /> generator or parent organization has on file one of the following: <br /> 1. Medical Waste Management Plan if the generator or parent organization is a large quantity generator <br /> or a small quantity generator required to register pursuant to Chapter 4. <br /> 2. Information Document if the generator or parent organization is a small quantity generator not required <br /> to register pursuant to Chapter 4. <br /> Please complete the information below and mail with $70.00 fee to: <br /> San Joaquin-County Environmental Health Department <br /> Medical Waste Management Program <br /> 304 East Weber Avenue, 3`d Floor, Stockton,CA 95202 <br /> Medical Waste Hauler Information <br /> p New 14 Renewal <br /> Medical Office/Business Name: Dor>Lnrc unsn; t i c)-f- Manteca <br /> Medical Office/Business Address: 1205. E North St. <br /> Mahteca, CA 95336 <br /> City State Zip Code <br /> Contact Person: Carmen Silva, CNO/COO <br /> Phone Number: 209-239-8-26-1 <br /> Storage Facility Name: n, Qr-t:9rs Hospital of Mantee <br /> Storage Facility Address: 1205 E. North St. <br /> Manteca, CA 95366 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Stericycle Inc. <br /> Permitted Treatment Facility Address: 135 W- swift- AvP <br /> Fresno, CA 93722 <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste(If more than 3,attach info): <br /> 1. Name: , r my M _T l va i n Title:Diroctor, yir-onme t&! Svcs <br /> 2. Name: Gni—Quin Title:AM Lead/ff on se-ke e per— <br /> CST <br /> 3. Name: Fr�ar��.awssn Title:PM Lead/u- <br /> e tt-s-e#eeper <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical wast .records shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: '�'` Date: i f Vo 5 <br /> Title: Chief Executive officer— <br /> DO <br /> ficerDO NOT WRIT ELOW THIS LINE <br /> R.E.H.S. Application Approval: p Date: _j_/�/ <br /> Expiration Date: _��/ Date Paid: /�/ Check#:'p `bt3 Received By: <br /> EHD 45-02-001 <br /> 10/7/2003 <br />