Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> FIL ,9 O P <br /> ? EN*ONMENTAL HEALTH DEPARTAT <br /> N' 1 <br /> 600 East Main Street, Stockton, CA 95202-3029 s Wf <br /> w ® Fd <br /> .,� �P • Telephone:(209)468-3420 Fax: (209)468-3433 Web:ww .sjgov.org/ehd F��p ?? <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION oFpMgFhti�- <br /> r <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 <br /> Medical Waste Hauler Information <br /> ❑ New Renewal <br /> Medical Office/Business Name: D r-4 fA— 'R 14 a!a►Le ,tt - ,p, ca9P <br /> Medical Office/Business Address: // Z. I W, — A 5 <br /> Lo o t, cL Ar 9S';IL4.ta <br /> City State Zip Code <br /> Contact Person: C> %4:� p ,Glt S70- P- 7— <br /> S <br /> Phone Number: 2® ,3 -- -s Af. <br /> Storage Facility Name: Amp v AN c ar o 1ZGtp <br /> Storage Facility Address: l o .�S 1 .Ses p 4r_ <br /> City State Zip Code <br /> Permitted Treatment Facility Name: S`F'. cJrY+_[ iG A�4 ,Cp 14X ^SZX- S7-X-atS <br /> Permitted Treatment Facility Address: Z� <br /> m <br /> 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: h"i�_� � Title: <br /> 2. Name: /Z.a O Ar L Z,-&*A, Title: _ �T- <br /> 3. Name: ��//��% / t�,�eTitle: A ,��-]►� <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 /> Applicant Signature: C ` ��� �'� Date: Z Z (� c <br /> Title: 70 <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: _ �+.� C9...91�..�_ Date: /0Q <br /> Expiration Date: r Date Paid: / /�Gaslr Check#: a y Received By: <br /> EHD 45-01 <br />