Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> EOR.ONMENTAL HEALTH DEPARTONT <br /> 600 E. Main Street, Stockton,CA 95202-3029 <br /> (209)468-3420-Fax.(209)468-3433 - Web:www.co.san-joaquin.ca.us/ehd9 <br /> rl; 9 <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION'"­,/r,,/ tl" <br /> TRTuDgy IIS D"/ IP R H 4 uD►thy HEbQg(xFP Stft" SurVjEht tRthH"O I-HIcIX7WI34HO D41-P 1-ht Act",thMR4&&g <br /> conditions must be metal <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 followingW <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$70.00 fee to: <br /> San goaquin County Environmental Health Department <br /> Medical t aste Management Program COP? <br /> 600 E.Main Street, Stockton,CA 95202-3029 <br /> Medical Waste Hauler Information <br /> [jj New ❑ Renewal ` - <br /> Medical Office/Business Name: L� Li vv SC-ra UL. <br /> Medical Office/Business AddressW 54b O l Y t 7 <br /> Cleo-dalAd n H i 2-S- <br /> City State wip Code <br /> Contact Personal I AeYfi ,)arpbs nv� i t,a,i <br /> Phone NumberW Z 1 (0 511 53 12 Lt b ( '6bQ vi- 1$44 W' ;� <br /> Storage Facility Name: PJI/A <br /> Storage cacility AddressW <br /> City State wip Code <br /> Permitted Treatment Facility Name: r i a h t . ►�1a �a�G-k <br /> Permitted Treatment cacility AddressW IS = IbL,9 <br /> 1 r h 2 5("1 <br /> City State wip Code <br /> List all employee names and titles authorized to transport the medical waste(If more than 3,attach info)W tt A rrA C HcD <br /> 1.NameW TitleW <br /> 2.NameW TitleW <br /> 3.NameW TitleW <br /> A copy of this exemption and a tracking document shall be in FP S%tHs SRsIksBQI)ADffl le H while transporting medical waste. In <br /> DOGNWQ D(41FISIH N P IEDDOwIkWQI M shDt EHN[fWQE0fl BHWliltls IAJh}D(Y►'FUUH SUV1sN0n MRid. <br /> Applicant SignatureW DateW ?'19 /V7 <br /> TitleW 'Wy- 14', <br /> DO NOT WRI E BELOW THIS LINE <br /> R.E.H.S. Application Approval W DateW /�/ <br /> Expiration DateW /�_/ Date PaidW g / 2 / mash or ec /(�, Received ByW-� <br /> q� <br /> EHD 45-02-001-web <br /> 10/7/2003 <br />