Laserfiche WebLink
le <br /> ° PA�'ANElyr <br /> ' ''O SAN JOAQUIN COUNTY REC <br /> _:--;:tea:� EIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 FEB i Q 2�� <br /> (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd EALrH 0 UMF <br /> 9 •:.,r •''� ENVIRON C0Uh7Y <br /> HEALTH DFagR�A1 <br /> b1Fh? <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <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, 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 Waste 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. Information Document if the generator or parent organization is a small quantity generator not required to <br /> - - 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 APPROVED,/� , <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Medical Waste Hauler Information <br /> ❑ New ❑ Renewal <br /> Medical Office/Business Name: Stnrlri nn rrn; �; o.a Cnhnnl <br /> Medical Office/Business Address Di in <br /> —701 N_ Mad; son St- <br /> Stockton CA 95202 <br /> City State Zip Code <br /> Contact Person: Janice Bates Administrator <br /> Phone Number: 209-933-7060 <br /> Storage Facility Name: Stockton Unified School District, Health Service <br /> Storage Facility Address: 975 North D. 6u- Stockton, <br /> City State Zip Code <br /> Permitted.Treatment Facility Name: Stericycle, Inc. <br /> Permitted Treatment Facility Address: <br /> Frr�cnn r'A A'�777 <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: — Please see attached list Title: <br /> 2. Name: Title: <br /> 3. Name: Title: <br /> A copy of this exemption and a tracking document shall in employee's possession at all times while transporting medical waste. In addition,all copies of <br /> medical waste records shall be kept on file at gene or health care professional's facility. <br /> Applicant Signature: c-c <br /> Title: Date:. 1 /17/14 <br /> DO NOT WRITE BELOW THIS LINE <br /> RENS Application Approval: 1 --� Date: <br /> Expiration Date:�/�/W-Date Paid: 2--- // 2/ Cash or hec :1Q5�71WO Received By: d¢ <br /> EHD 45-015/2/12 <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />