Laserfiche WebLink
Joaquin County Public Health Seees <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To quality for a "Limited Quantity Hauling Exemption" pursuant to the"Medical Waste Management P,ct", the following <br /> conditions must be met: <br /> i he generator or health care professional generates less than 20 pounds of medical waste per weak, transports 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 or a small <br /> 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 to <br /> register pursuant to Chapter 4. <br /> PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH Sol FEE TO: <br /> San Joaquin County Public Health Services r <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> 0 New ly� Renewal <br /> Medical Office/Business Name:. St . Joseph' s Community Home Care <br /> Medical Oice/Business Address: Z Code: A 5 1 Q <br /> City: State: rn Phone� 478-9947 <br /> Contact Person: <br /> Storage Facility Name: ' <br /> Storage Facility Address: State: C A Lp Code: A 5 2 1 9 - <br /> City: <br /> Permitted Treatment Facility Name: S r_ ___,_ ® M o a i n t e r <br /> Permitted Treatment Facility Address: 18 0 0 N. C a l i f o r n i a S t <br /> k State: ( A Zp Code: 9 5 2 0 4 <br /> City <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> Title: RN A n� n� Gtrator <br /> 1- Name: Carol Har in Title: RN . linica Sin visor <br /> 2- Name: Mariorie Farrell - T'itie:.�:� �„�e Manager - <br /> 3- Name: Cheryl Hitchcock <br /> A copy of this exemption and a tracking document shall be in employee's possession at ail times while transporting medical waste. in <br /> addition. all copies of medic l waste records shall a kept an file at generatoe's or health care professionars faeitity. <br /> Applicant Signature: <br /> Date: <br /> Title: <br /> Do Not Write Below This Line <br /> R.E.H.S. Application Approval: eDate:�Expiration Date. -/31 /4 a2 <br /> EH4502 1003-96 Date Paid 1Z-/ l / ® L �h or Check _ (3to�4S (circle) Acct__ — <br />