COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

JAN J OAQUIN COUNTY ni C 0 P yp��YEAONMENTAL HEALTH DEPARA14 """ RL. MV C,T 600 East Main Street, Stockton,CA 95202-3029 `P Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd JAN 19 2010 gGiko¢a SAN J AQUIN COUNTY APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPT1 RQE ENTALALTH T 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 generator not required to register pursuant to Chapter 4. Please complete the information below and mail with$77.00 fee to: San Joaquin County Environmental Health Department Medical Waste Management Program 600 East Main Street, Stockton, CA 95202-3029 Medical Waste Hauler Information F1 New ❑Renewal rr� Medical Office/Business Name: .�iAxV (r(+vCFi E� �ocu Si12i�i. l'a'S L:-,H S52 166-5. Medical Office/Business Address: j&/0 (,U a;/ Rp i�.ZCi--Tont . CA 95-a o-1 City State Zip Code Contact Person: L//,/ .LCS77'E�2 RC)VE.:E7 o`82145V Phone Number: c9o9-953-87,99 c. q,:5 3 -R-7cq, 9' Storage Facility Name: Q a its Storage Facility Address: 1q00 (A)67S7- SWil,r4 jZ014i , c 9sa0•2 City State Zip Code Permitted Treatment Facility Name: _ s i E�i r_.�1 9 1 r�I{� CZi rel�v.'�l fY1 �1 8�+� VGa�+� 1 t Permitted Treatment Facility Address: (000 4W City State Zip Code List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): 1.Name: EVALYiI/ 1 om5z Title: � iflAovL A/L44sc= 2. Name: REry e-E r),z31z;ay Title: �64ou- 3.Name: J Age, ,j Title: Jje�L•-1-�-� ,Sixdice- Su mei"IV oF-5 Di 2 e-e--i Iz., GLJ tq 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 medicMscords shall be kept n file at generator's or health care professional's facility. f Applicant Si a e: ate: Title: DO NOT WRITE BELOW THIS LINE R.E.H.S. Application Approval: Date: Z-/94�tM Expiration Date: O Date Paid: Cash or heck#*:� q s fog Received By:� EHD 45-01