Laserfiche WebLink
G� SAN JOAQUIN COUNTY <br /> Ge `, ENSONMENTAL HEALTH DEPARTI C E CO", <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web: www.sjgov.org/ehd ! <br /> APPLICATION FOR A LIMITED UANTITY HAULING EXEMP FI'bN"jai;^QCCIi'L;IN,c,, Up,,r <br /> Q r—f\I \!iV[{�iTAL <br /> "EALTI f DEPART vIE-PIT <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 Addus Healthcare <br /> Medical Office/Business Name: 817 COOee Rd - Bldg B 1 <br /> Medical Office/Business Address: Modesto, CA 95355 <br /> City Zip Code <br /> Contact Person: <br /> Phone Number: - <br /> . ,,,,s Healthcare <br /> Storage Facility Name: Q-7- I <br /> Y ., <br /> Storage Facility Address: ) ' 7 � � �% . — <br /> dPCto'._C ' <br /> City , � State Zip Code <br /> Permitted Treatment Facility Name: \._ <br /> Permitted Treatment Facility Address: <br /> _ , ^7 <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: - crcJ <br /> 3. Name: Till . G�P . <br /> A copy of this exemptiop-and tracking document shall be in mployee's possession at all times while transporting medical waste. In <br /> addition,all copies of med4wasrecords shall be kept on fZrator's or health care professional's facility. <br /> Applicant S ature. Date: <br /> Title. <br /> DO NOT WKITE BELOW THIS LINER.E.H.S. Application Appro/val: -A@ L&gin Date: <br /> Expiration Date: /�/ // Date Paid: �/ 3 / C- slLQx CheckOS351 Received By: <br /> EHD 45-01 <br />