Laserfiche WebLink
' -_-•� AG� Av <br /> SAN JOAQUIN COUNTY J FAV T <br /> {i ENVIRONMENTAL HEALTH DEPARTMENT <br /> ••�� Edd East Main Sheet,Stockton,CA 95202-3029 N �VqqQ�i 2QlQ <br /> Telephone:(209)468-3420 Par:(209)468-3433 Web:www.s ov.or�ehd 7 y),o N co <br /> Jg O�cpMFM o,�lY <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION �V NT <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management Act",the following <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$77.00 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 /> *New ❑Renewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: 170--1 10 <br /> fj()41 aA-P-cc -CIA <br /> City State Zip Code <br /> Contact Person: V-1 <br /> Phone Number: <br /> Storage Facility Name: <br /> Storage Facility Address: , <br /> City State Zip Code <br /> Permitted Treatment Facility Name: i rAY1Ct <br /> Permitted Treatment Facility Address: <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: ax Title:G ep— Ae.O-L{ <br /> 2.Name: , Title Q A.�Wl <br /> 3.Name: e Title: 1<y/\) <br /> A copy of this exemption and a track' document shall be in a ployce's possession at all times while transporting medical waste. In <br /> addition,all copies of medical wast cords shall be -ept on 11-m- t en tor's or health care professional's facility. <br /> Applicant Signature: Date: C7 <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: �1. �ltDate: 10 / / 16 <br /> Expiration bate:lit-/ 61 Li-t-> Date Paid: (P l I l (p Cash-oreftm #: 0101 q•D Received By: <br /> MID 45.01 Ma&t <br /> 1 V 19ios <br />