Laserfiche WebLink
o c SAN JOAN COUNTY <br /> o�Z-+ ENANTAL HEALTH DEPARTMO <br /> „ 600 East Main Street, Stockton, CA 95202-3029 <br /> ;P Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> 4��FOR <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <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$72.00 fee to: <br /> San Joaquin County Environmental Health Department PAYMENT <br /> Medical Waste Management Program ! r--(71(=I\IPF) <br /> 600 East Main Street, Stockton, CA 95202-3029 1C 2 1 2007 <br /> Medical Waste Hauler Information SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ❑ New Renewal HEALTH DEPARTMENT <br /> Medical OfficefBusiness Name: ( ►1� ✓ t�� �- ���� C( <br /> Medical Office/Business Address: S _ �r »�c, <br /> City State Zip Code <br /> Contact Person: <br /> Phone Number: C Ll <br /> Storage Facility Name: <-- <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: I C - �jt\( <br /> Permitted Treatment Facility Address: J. <br /> City ' State Zip Code <br /> List all employee na r <br /> and titles authorized to transport the medical waste(If more than 3, attach info): <br /> z ,l <br /> 1. Name: .�. � �� t-� ��_ �,��,-�- Title: <br /> 2. Name: Title: <br /> 3. Name: Title: <br /> A copy of this exemption and a tracking document shall be in em loyee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical waste rec ds s 1 b e t at generator's or health care professional's facility. <br /> Applicant Signature - Date: h <br /> Title: '; c: G4I-S J 1' <br /> DO NOT WRI;jj BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: <br /> Expiration Date: I Z.-/ 31 / OyDate Paid: l a( l Q Cash or hec :1, Received By: <br /> EHD 45-01 <br /> 10/02/07 <br />