Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> u ENviF MENTAL HEALTH DEPARTME <br /> 600 East Main Street, Stockton, CA 95202-3029 4 r d _;'�, } <br /> `\ ., P • Telephone:(209)468-3420 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTI ,N,, 010 <br /> , �'��C?Uli�!C <br /> UNT <br /> To qualify for a "Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Managemetit=Aat'l;tlie' (ylibtwing <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 fie 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 PRenewal <br /> Medical Office/Business Name: S r <br /> Medical Office/Business Address: t DIAS YJ (�j A17S,1JW- -k-- <br /> City State Zip Code <br /> Contact Person: <br /> Phone Number: G . ® - .4& l� <br /> Storage Facility Name: -s4w\,& as Qr6mie- <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: . SWYR <br /> 6 e—# <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: Title: <br /> 2. Name: Title: <br /> 3. Name: Title: <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 med4wasecords shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: Date: <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval. � Date: A2d-2a/Ab— <br /> Expiration Date:I2. /'b% /k, Date Paid: C-astrer-Check#: 3 t�S.GD Received By: <br /> EHD 45-01 <br />