Laserfiche WebLink
SAN JOAQUIN COUNTY 10 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3`d Floor, Stockton, CA 95202-2708 EC 2 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd S 9 Z��6 <br /> t f� ,10 <br /> /V QU//V U <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPT W1,110ki; ���� <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 <br /> Medical Waste Management Program <br /> 304 East Weber Avenue,3`d Floor, Stockton,CA 95202 <br /> Medical Waste Hauler Information <br /> ® NewLA <br /> Renewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: 1-4%l O <br /> City State Zip Code <br /> Contact Person: Z� <br /> Phone Number: AS-Sq- 1LA <br /> Storage Facility Name: iA Y'Y\ cynS�12— <br /> Storage Facility Address: _ . _gip® Sox ruc� <br /> City State Zip Code <br /> P <br /> .Permitted Treatment Facility Name: <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: Title: <br /> 2. Name: Title: <br /> 3. Name: Title: <br /> A copy of this exemption and a tracking document shall be i1 em yee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical waster cords s 11 a ke i fl at enerator's or health care professional's facility. <br /> Applicant Si nature: Date: d 6 <br /> Title: <br /> DON T WRI E BELOW THIS LINE <br /> R.E.H.S.Application Approval: Date: ��- <br /> Expiration Date: _L7/ .3/ /Dq Date Paid: Check Received By:_ <br /> EHD 45-01 <br /> 07/31/06 <br />