COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

s Statetof California—Health and Welfare Agency ® Department of Health Services Medical Waste Management Program ` LIMITED QUANTITY HAULING EXEMPTION County: Pursuant to Chapter 6.1, Division 20, of the Health and Safety Code, the following person(s)are authorized to transport regulated medical waste from the point of generation to a point of storage or treatment under the following conditions: 1. Your office generates less than 20 pounds of medical waste per week and transports less than 20 pounds of medical waste at any one time as specified in Section 25061. 2. Your office maintains a tracking document with the required contents as specified in Section 25063(b). 3. You or a designated staff member of your facility transport the medical waste to a permitted medical waste treatment facility, a permitted transfer station, or another point of consolidation as defined in Sections 25070.2 and 25070.3. Home health care facilities may accept medical waste only from their staff members operating under this exemption. 4. A copy of this exemption form and a tracking document, as described above,MUST be in the specified employee's possession while transporting the medical waste. 5. Your office notifies the Department of any changes in the information supplied on this form. 6. Your office submits an administrative fee of$25 for the initial exemption, which includes up to 4 names. There is an additional charge of$5 for each name submitted beyond the first 4,not to exceed a grand total of$50 for the application. 7. Your office submits a completed application and a statement describing your need for this exemption. Include in this statement a description of the relationship between your facility, the person transporting the waste, and the point of waste consolidation. In order to receive a Limited Quantity Hauling Exemption, complete the following information and return this form for final approval to: California Department of Health Services Medical Waste Management Program 601 North 7th Street P.O.Box 942732 Sacramento, CA 94234-7320 GENERATOR IDENTIFICATION REGISTERED/PERMITTED STORAGE FACILITY, TRANSFER STATION, OR POINT OF CONSOLIDATION (See Abp e) Name: Address: I i l Q Q Telephone No: TREATMENT FACILITY IDENTIFICATION i Name: n Address: '1 ^ Employees authorized to transport medic waste: t I;k Milo, � 1. 112. RN 3. 1W 4. (If additional names are to be added,attach a separat sheet of paper to this form.) Chief Signature of Generator California Department of Health Services r/) Medical Waste Management Program �l Expiration Date: Name of Generator(Please Print) *Note: This exemption is valid for one year. This exemption Is not valid unless both the Generator of the waste and the Department have signed this form. This exemption is void#f any of the conditions specified above are violated or exceeded. EH 253(6/94)