COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ARONMENTAL HEALTH DEPARTONT I1 `' 600 East Main Street, Stockton, CA 95202-3029 FILECOPY \ -Pi Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd aLi't_aRia% 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, 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 gen r uired to register pursuant to Chapter 4. RECEf VEd Please complete the information below and mail with $77.00 fee to: DEC Z 12009 San Joaquin County Environmental Health Department SAN JOAQUIN C Medical Waste Management Program H�TH pE NT Nn 600 East Main Street, Stockton, CA 95202-3029 Medical Waste Hauler Information F1 New Renewal Medical Office/Business Name: 17T br L c-, 30 V AAb G Z 77ly C Medical Office/Business Address: `/' r G,- �,%s'� 4 City State Zip Code Contact Person: C- ,I5C-- 0 T Ste, Phone Number: o -5-3-, FL-3 4 Storage Facility Name: Ab U Wo e-L p ;�P ' A ��-- Storage Facility Address: _fes f o 4�A 112 lu o/t/ �-V 15--: City State Zip Code Permitted Treatment Facility Name: sus Permitted Treatment Facility Address: 1.3g Q e Tr4OR i � t— c, CA- 1-4-S-77 - city i"4-S-?City State r Zip Code List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): 1. Name: 0`l< , ,(d f-0-X-�e S , Title: /+R ee ( _. 2. Name: �J- kf / >'-g K fS/.S.,gF-P Title: /+ i C 9'-r— 3. Name: f{- 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: �' _ :,y, �� Date: -7-o Title: Q� DO NOT WRITE BELOW THIS LINE R.E.H.S. Application Approval: ., = Date: x/51 /tet Expiration Date: 13,_/3L_/ 10 Date Paid: 1.2-1 .2-1 / 0'? Cash or Check Received By: bJ EHD 45-01