Laserfiche WebLink
°�QUIN' ° SAN JOAQUIN COUNTY <br /> __ { ENVIRONMENTAL HEALTH DEPARTMENT PAY,�F <br /> • 1868 East Hazelton Avenue, Stockton, CA 95205-6232 i ?FCENED <br /> (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd DEC ' <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION, , cov <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, 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 <br /> small quantity generator required to register pursuant to Chapter 4. <br /> 2. Information Document if the generator or parent organization is a small uantity generator not required to <br /> register pursuant to Chapter 4. <br /> Please complete the information below and mail with $77.00 fee to: �Z1 <br /> San Joaquin County Environmental Health Department AP 0V <br /> Medical Waste Management Program ' <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Medical Waste Hauler Information <br /> Lian Soung, M.D. George Herron, M.D. <br /> ❑ New a'�Renewal 1610 N Eldorado St 1610 N. Eldorado St. <br /> Medical Office/Business Name: Suite 17 Suite 17 <br /> Medical Office/Business Address StOcKtOn, CA 952-,�4 StOckt011, H <br /> City INjQState Zip Code <br /> Contact Person: <br /> Phone Number: _ <br /> Storage Facility Name: L' <br /> Storage Facility Address: <br /> CityS. C� q�Statg � Code p3�ZZ <br /> ✓V / 'J J <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: 3 InJ. <br /> city--'--/ State Zi Code <br /> � zz <br /> List all employee name and titles authorized to transport the medical waste (If more than 3, attach info): <br /> 1. Name: Title: <br /> 2. Name: AlTitle: <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 addition,all copies of <br /> medical waste records shall be kept on file at ge eratoes or health care professional's facility. <br /> / 2- <br /> Applicant <br /> Applicant Signature: DC, --. t-- Date: <br /> Title: >n,� <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval:—j �.-� t J Date: .0/ /b/l <br /> Expiration Date: /Z / 1 / 4 Date Paid: l/ l 13 Cash or hec : G92-G Received By: <br /> EHD 45-015/2112 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />