COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

R" T SA UAQU1 GOUNt y ENVIRONMENTAL HEALTH DEPARTMENT •` 1868 East Hazelton Avenue, Stockton, CA 95205-6232 (209)468-3420 Fax: (209) 464-0138 Web:www.sjgov.org/ehd ��FOR APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION 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, transports 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. Please complete the information below and mail with $77.00 fee to: PAYMENT RECEIVED San Joaquin County Environmental Health Department APPROVE DEC 16 2013 Medical Waste Management Program r� 1868 East Hazelton Avenue, Stockton, CA 95205-6232 " SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Medical Waste Hauler Information D New Renewal J, Medical Office/Business Name: Medical Office/Business Address 1 W� .S' City State Zip Code Contact Person: 11 fug Phone Number: 1-�-09- 333- g131Y�3 Storage Facility Name: AdLI'mud lmmhm cwt Storage Facility Address: 0 ted t City State Zip Code Permitted Treatment Facility Name: Permitted Treatment Facility Address: 13,7,7 Y. =-[ Ja!i Lel, ` dty C.A 95`J'7 7 City State Zip Code List all employee names and titles authorized to transport the medical waste(If more an 3, attach info): 1. Name: k 11 iu v' awp*- Title: U z 2. Name: ;.a 4,014 k�cem Title: 3. Name: Title: 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: Date: Title: DO NOT WRITE BELOW THIS LINE REHS Application Approval: �= Z ^Xent , Date: J,&/ 111 Expiration Date:JW A I / 1 Date Paid: Imo/A- /13 Cash o Chec IV S Received By: EHD 45-015/2/12 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION