Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> y z{ Ei ONMENTAL HEALTH DEPARTONT <br /> 304 East Weber Avenue,P Floor,Stockton,CA 95202-2708 PAYMENT <br /> (209)468-3420-Fax:(209)468-3433- Web:w-ww.co.san-joaquin.ca.us/ehd RECEIVED <br /> qt'FORM <br /> i <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIOR 1 5 2003 <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste ManagerneWAr.awwRing <br /> conditions must be met: <br /> HEALTH DEPARTMENT <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$70.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program 000A, <br /> 304 East Weber Avenue, 3d Floor, Stockton,CA 95202 <br /> Medical Waste Hauler Information <br /> El NewRenewal L1 <br /> Medical Office/Business Name: 0.�&e-r- U VA lL <br /> Medical Office/Business Address: Ll ~' 1� <br /> City - State Zip Code <br /> Contact Person: t « �� <br /> Phone Number: 7 r)a 3v �"�t�> <br /> Storage Facility Name: S 4�n n,� ��0 vCL <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: \.C- C-- <br /> Permitted Treatment Facility Address: <br /> s_)?c^w.fi <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 /> 1. Name: tw-- Title: <br /> 2.Name: Title: <br /> 3. Name: Title: <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical waste records shall b e t on file at generator's or health care professional's facility. <br /> Applicant Signature: Date: 12-1 Mil D.6 <br /> Title: <br /> DO NO WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: L/ 9 /O <br /> Expiration Date: / / Date Paid: Cash o heck l�Received By: <br /> END 45-02-001 <br /> 10/7/2003 <br />