Laserfiche WebLink
,oPqu►,N' •�o SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <br /> C'qt! <br /> APPLICATION FOR A LIMITED TITY 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 <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> 0 New ❑ Renewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address <br /> City State Zip Code <br /> Contact Person: <br /> Phone Number: <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: _ <br /> Permitted Treatment Facility Address: <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 addition,all copies of <br /> medical waste records 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 /> REHS Application Approval: Date: <br /> Expiration Date: / / Date Paid: / / Cash or Check#: Received By: <br /> EHD 45-01 11/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION <br />