Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> _ cZ ENOONMENTAL HEALTH DEPARTM� <br /> { F CQYpt�01�ENT <br /> 600 East Main Street, Stockton, CA 95202-3029 _� F70 <br /> q 20 Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd 0 <br /> 07 <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMliipo uiN oouNn, <br /> At7N D p'rAL <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management Act", the foing <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$72.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> Q New 2-1�enewal <br /> Medical Office/Business Name: C dr S �dS p �C,Atf C--- <br /> Medical Office/Business Address: S <br /> YY\a -e C C. C r, 175-33 <br /> City - State Zip Code <br /> Contact Person: �r�c m e v� \. y C,- C- n o C.o a <br /> Phone Number: O 3 - 4�5,3 6/ <br /> Storage Facility Name: p C. o; ©� MCA e c✓� <br /> Storage Facility Address: O <br /> Ct 0- <br /> 3 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: S;9_(-'1 (" _ter^\e_ -:17—V\c, <br /> Permitted Treatment Facility Address: o v <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): c <br /> 1. Name: 0Q Title: t� -Cc�C C.AQ (6>%&r,,&��a1 Se- <br /> 2. Name: K v\- Title: N NM - <br /> 3. Name: rx ' e--)�,z Title: <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 medi asteeyreecords shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: 1� � Date: 12--1 1 o> <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: _ �1Date: <br /> Expiration Date: � L/�D to Paid: g,/ \0 / 6 l Cash-ar Check#: g jI l 3�� Received By: _ <br /> EHD 45-01 <br /> 10/02/07 <br />