Laserfiche WebLink
22 2013 3:45PM HP Fax page 1 <br /> Jan. 22, 2013 2:40PM San Joaquin County No. 0431 P. 2 <br /> .• SAN JOAQUIN COUNTY �e <br /> 15NVIRONMENTAL HrALTH DEPARTMENT a <br /> 1868 East Hazelton Avenue,Stockton.CA 9S205-6232 <br /> (209)468-34.20 Fax:(208)464-0138 Wob:www.sjgov.org/ehd <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To quarify 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, transports 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 Wastiq Management Plan if the generator or parent organization is a large quantity generator or a <br /> small quantity generator required to register pursuant to Chapter 4. <br /> 2. lnfnrmafion Document if the genetator or parent organization is a small quantity generator not n:quired to <br /> register pursuant to Chapter 4. <br /> PAYMEN-r <br /> Please complete the information below and mail with$77.00,fgg$gO�E ! RECEIVE® <br /> San Joaquin County I~mrirohmental Health Department cC� ' , 20112Medical Waste Management ProgramI/ <br /> 1868 East Hazelton Avenue,Stockton, CA 95205-6232 EWR'ON q Gp�" <br /> - HEALTHDE AR�hL <br /> Ek? <br /> . Medical Waste Hauler Information - <br /> ❑ New g(Renewal <br /> � e r <br /> Medical OfticelBasinesr.Name: <br /> Medical Office/Business Address � � I =_ — <br /> t1Gtit' <br /> city Slats zip code <br /> Contact Person: In_ <br /> 'Phone Number - - $c _ <br /> Storage Facility Name: <br /> Storage Facility Address; <br /> City State ftp <br /> Permitted Treatment Faclilty Name; r <br /> Permitted Treatment Facility Address; <br /> Cipr Slate Zip Code <br /> List all employee n�tq�e and titles uthorized to transport the medlcal waste(If more than 3,attach info): <br /> 1,Name: s_n_ °t a� ICI Ifl�, Tido: ILM, p6a isc <br /> 2.Name: Title: <br /> 3,Name: Title; <br /> A appy of this exemption and a backing document*hall be in ornplaya■'s possoosion at all times wh)le transporting medical wade. In addition,all copies of <br /> medical waste mcorda&hall bo ke t on file at g ratoes or health caro professional's facility. <br /> Applicant Sign ure: Date: <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: ::,Q Date: 2jJ291-3- <br /> Expiration Date: 12J31 /,l� pate P2ic 1- 1 f 7/ I ash or Check#: /001 r.2db Remlved By: <br /> Elio 45.91 Wilt APPLICATION FOR A LIM ITED QUANTITY HAULING EXEM"ON <br /> Received Time Jan. 22. 2013 2:52PM No. 2143 <br />