COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

urN •.oZ SAN JOAQUIry COUNTY �11ONMENTAL HEALTH DEPART 304 East Weber Avenue, 3`d Floor, Stockton,CA 95202-2708 ®u 20D • �. P (209)468-3420•Fax:(209)468-3433 • Web:www.co.san-joaquin.ca.us/ehd ��►FOR�� APPLICATION FOR A LIMITED QUANTITY HAULING EXEMAN= To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management Act",the following conditions must be met: The generator or health care professional generates less than 20 pounds of medical waste per week,transport less than 20 pounds of medical waste at any one time,maintains a tracking document pursuant to Chapter 6 and the generator or parent organization has on file one of the following: 1. Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a small quantity generator required to register pursuant to Chapter 4. 2. Information Document if the generator or parent organization is a small quantity generator not required to register pursuant to Chapter 4. PAYMENT Please complete the information below and mail with$70.00 fee to: RECEIVED San Joaquin County Environmental Health Department DEC 82003 Medical Waste Management Program 304 East Weber Avenue, P Floor, Stockton, CA 95202 SAN JOAQUIN COUNTY ENVIRONMENTAL Medical Waste Hauler Ill r"Illat1011HFJ1J-THDEPARTMENT 1; � ❑ New O Renewal ' Medical Office/Business Name: IS L rfl- RA-01 c, c; Z Y i7,> - 3 ti CMedical Office/Business Address: ! Z t W - Ll/ -A-1 ,15- /�S^A-% S t� / v L� Ui' Li C/S� yO City State Zip Code Contact Person: Ko t+M Phone Number: 3 3 -- Storage Facility Name: AD f✓Ayvc E-t> � .i-t��'iiv�' C L�it�l F-E � Storage Facility Address: /C-"31 S a E41' (Z tiT G/1t i4 Cir- v D CSA-- 7�3-,-7- 'I-a City State Zip Code Permitted Treatment Facility Name: .S'7-�t� 6 �L c w , Permitted Treatment Facility Address: 115-7 6 H 1-7-,Q 104C-1C, fZ D City State Zip Code List all employee names and titles authorized to transport the medical waste(If more than 3,attach info): 1.Name:© •K.f(oi;Y+1[.sTjE-: o 1- S/C Title: A R R T-- 2.Name: R042 C4L-L A D, Title: A4 t;-' l - 3. Name: :J--5 k,-IV( E-CE R- cZ>0 j-&—/A-J Title: /)-R a 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 medical waste records shall be kept on file at generator's or health care professional's facility. Applicant Signature: LC , � S'tr' Date: Title: ,lt�a- ,C .,-, , DO NOT WRITELOW THIS LINE R.E.H.S. Application Approval: E Date: Expiration Date: Ll Date Paid: / Cash or��c ) �D l p,5/ 6' Received By: EHD 45-02-001 10/7/2003