Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> E HEALTH DEPARTP&T <br /> East Main Street, Stockton, CA 95202-3029 PONMENTAL <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> \[t;epRj <br /> L GU <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <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, 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 $77.00 fee to: <br /> San Joaquin County Environmental Health Department `= <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 0 ti C Cr Z 0 10 <br /> Medical Waste Hauler Information SAN.,,�OA(IlUlcoUN-IY <br /> ❑ New [Renewal HEALTH DEPARTMENT <br /> Medical Office/Business Name: r.A- <br /> Medical Office/Business Address: <br /> City State Zip Code <br /> Contact Person: /C Ka Z4,1-It-, <br /> Phone Number: -' -�-�� - <br /> Storage Facility Name: ,A o h7TZ5,i, <br /> Storage Facility Address: l6 �� Sc r i rz �t a,•J7 ,�F' <br /> City State Zip Code <br /> Permitted Treatment Facility Name: S' i c yA) <br /> Permitted Treatment Facility Address: .3 jEU s <br /> 572A— Cl 4 S", — <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: ko ' .S7—/-- Title: /�rA V l Sa. <br /> 2. Name: /1% 1! l /2 15 <br /> 3. Name: -�` A- L 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 be kept on file at generator's or health care professional's facility. <br /> 7 <br /> Applicant Signature: - Date: �~ <br /> � T <br /> Title: — / <br /> /! J rs ie <br /> DO NOT WRfITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: 'cuj•--- Date: -Z/ 15/10 <br /> Expiration Date: I L / 31 /�_Date Paid: / /;" Cash ori #: Received By: <br /> EHD 45-01 <br />