Laserfiche WebLink
y z� SAN JOAQUIN COUNTY <br /> EI&ONMENTAL HEALTH DEPA <br /> RT&T FILE <br /> COPY <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> q ;P Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd <br /> ��FOtZ <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 <br /> Medical Waste Program Management �� <br /> g g o 2061, <br /> 600 East Main Street Stockton CA 95202-3029 SAN jo <br /> ENV/popV N COUNTY <br /> Medical Waste Hauler Information HEAITHpEARM�NT <br /> Q New 10 Renewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: j S -e <br /> S+nur,i ovl 0A 4saOY <br /> Cityf j State Zip Code <br /> Contact Person: A i 41 l p SA U / <br /> Phone Number: 0 <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: 4er I' Li lrje <br /> Permitted Treatment Facility Address: <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 /> A <br /> 1. Name: L Title: 09CIII <br /> 2. Name: Title: ` As <br /> 3. Name: Title: <br /> c ti 1z:2t 1�ttA�� <br /> A copy of this exemption and a tracking ocument shall be in employee's possession at all times w e tr sporting medical waste. In <br /> addition,all copies of medical waste reco ds shall be kept on file at generator's or health care professional's facility. <br /> Applica t Signature: Date: 1/-��' b 7 <br /> Title: fr-Si crt.t <br /> DO NOT WRITE BELOW TRIS LINE <br /> R.E.H.S. Application Approval: Date: 4/ /Q- <br /> Expiration Date: l 2-f 3/ / Date aid: /07-/ a0/U7 Cash or Chec Received By: <br /> EHD 45-01 <br /> 10/02/07 <br />