Laserfiche WebLink
',o coG SAN JOAQUIN COUNTY <br /> z ENANMENTAL HEALTH DEPARTM* <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> ;P Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <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 PAYMENT <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 4 20%1r <br /> Medical Waste Hauler Information SAN JOAQUIN COUNTy <br /> ENVIRONMCNTAL <br /> Q New Q Renewal HEALTH DEPARTMENT <br /> Medical Office/Business Name: �f Volf t _ <br /> Medical Office/Business Address: CQ -S <br /> S� <br /> City _ State Zip Code <br /> Contact Person: C l l r.4 <br /> Phone Number: 95`r- 0 0 <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: IA- <br /> Permitted <br /> Permitted Treatment Facility Address: Z A <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste(If mo tha 3, attach info): <br /> 1. Name: Title: <br /> 2. Name: C4— Title: &AJ 4 <br /> 3. Name: lS Title: <br /> A copy of this exemption and a acking document shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical waste records shall be kept on file at generator's or health care professional's facility. <br /> Applicant Si ature: G` � � L Date: <br /> Title: �1- <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: <br /> Expiration Date: / / Date Paid: Cash or eck# %V,5 Received By: (�f <br /> ExD 45-01 <br /> 10/02/07 <br />