Laserfiche WebLink
Sa f quin County Public Health Servo <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> Tc 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, transports <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: p less <br /> 1- Medical Waste Management Plan if the generator or parent organization is a large quantity-venerator or <br /> quantity generator required to register pursuant to Chapter 4. a small <br /> 2- Information Document if the generator or parent organization is a small quantity generator not required Q to <br /> register pursuant to Chapter 4. <br /> PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH $67 FEE TO: <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> P.O. Box 388 (COO [P'f <br /> Stockton, CA 95201-0388 <br /> /New ❑ Renewal Medical Waste Hauler Information <br /> Medical Office/Business Name: CARE HOME HEALTH <br /> Medical Office/Business Address: 303 W. Joaquin <br /> City: San Leandro <br /> Contact Person: Amanda Juarez State: Zip Code: <br /> Phone#:5T0_—_8V5T6U4-- <br /> Storage Facility Name: Care Home Health <br /> Storage Facility Address: 303 W. Joaquin <br /> City: San Leandro <br /> State: CA Zip Code: <br /> Permitted Treatment Facility Name: Integrated Environmental Systems <br /> Permitted Treatment Facility Address: 499 High <br /> City: Oakland <br /> State: CA _Zip Code: <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach <br /> 1- Name: information. <br /> 2- Name: Title: RN <br /> 3- Name: " �'� Title: <br /> Title: PL.v <br /> f this <br /> on and a <br /> cking <br /> shall <br /> addition, all copies moft'medical waste records shalltbe kept in <br /> fie at ge erattoor s o ion at all times while transporting medical waste. In <br /> r health care professional's facility. <br /> Applicant Signature: <br /> Title: <br /> Date: <br /> Do Not Write Below This Line <br /> R.E.H.S. Application Approval. <br /> EH4502 10-03-96 Date: IZ/ }Expiration Date• �L%2� / 93 <br /> Date Pai I Z/ ( / Cl Cash or Check #3!1Z—'_34__Zg <br /> �4_ (circle) Acct <br />