Laserfiche WebLink
n° w'1N o SAN JOAQUIN COUNT <br /> y )✓. QNMENTA.L HEALTH DEP <br /> 304 East Weber Avenue,3"'Floor,Stockton,CCA952*02-27OF <br /> Telephone:(209)468-3420 rax:(209)468-3433 Web:www.sjgov.org/ehd <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPac,,N�`1004 Tii�NMFCQv <br /> `1'o qualify.for a"Limited Quantity Hauling Exemption"pursuant to the "Medical Waste Management Act , �10 ing <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 $70.00.fee to- <br /> San Joaquizi County Etivironmental"Hedlth Department — - <br /> 304 East Weber Avenue, P floor, Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> ❑ New VRenewal <br /> Medical Office/Business Name: ZUA/ Scruh� MDY'Ytn-, A7 1) <br /> Medical Office/Busitless Address: ZOO 4APO -J <br /> IMIrIk--burr, c A <br /> City State lip Code <br /> Contact Person: Gert. 1�Ju-,�'�- <br /> Phone Numbcr: <br /> Storage Facility Name: c Cl­­ �"r' cfrr�,;t5 <br /> 4 <br /> Storage Facility Address: r-� Al 6 -�rI <br /> City State 7 p Code <br /> Permitted Treatment Facility Name: 1. <br /> Permitted Treatment Facility Address: , ��L6 Z - <br /> Ak4bye t-4, <br /> frt�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: 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 qe kept on file at generator's or health care professional's facility. <br /> Applicant Signature: Date: ,yo <br /> Title: <br /> DO NQT WR1BELOW THIS LINE <br /> i <br /> R.E.H.S. Application Approval: Date: <br /> Expiration Date: 1 /OG Date Paid: / / Cash or eck :—�� Received By: . <br /> M-M 45-02-001 <br /> M/712n0a <br />