Laserfiche WebLink
Saijoaquin County Public Health Servs <br /> Environmental Health Division <br /> Medical Wasie Management Program <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Acr. the following <br /> conditions must be met <br /> The generator or health care professional generates less than 20 pounds of medical waste per weep transports less <br /> than 20 pounds of medical waste at any one time, maintains a 4ac king document pursuant to Chapter 6, and the <br /> generator or parent organization has on file one of utie following: <br /> 1- Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a small <br /> quantity generator required to register pursma 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. . .A <br /> PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WrrH UT FEF=•f0: <br /> San Joaquin County Public Health Services 2 _;v <br /> Environmental Health Division <br /> Medical Waste Management Progra - + <br /> 304 E Weber Ave (� <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> O New Q Renewal <br /> Medical Office/Business Name: HOSPICE OF SAN JOAQUIN <br /> Medica( Office/Business Address: 2609 E. Hammer Lane <br /> City: / Stockton State: CA Zip Code: 95210 <br /> Contact Person: Gary Hoover Phone* 957-3888 <br /> Storage Facility Name, HOSPICE OF SAN JOAOUIN <br /> Storage Facility Address: SEE ABOVE <br /> Slate• Zip Code: <br /> City_ <br /> Permitted Treatment Facility Name: KOFRAN INDUSTRIES z <br /> Perrnifted Treatment Facililty Address: CA <br /> [fid <br /> City- ��Cra. <br /> 'n �o� State: _- -----Z�p Code• q eta <br /> List all employee names and titles authorized to tarsport the medical waste. If not enough space, attach information. <br /> �- Name: SEE ATTACHED Title: <br /> 2- Name: T'rfle• <br /> 3- Name: Tide: - <br /> A copy of this exemption and a uacidrg document shalt in mopicyows possession at an dines while transporting mecacal waste. in <br /> addition, aft copies of medical waste records shall be pt at Me at anneratorAs or health care profe=omrs faczBiy. <br /> Applicant Signature: <br /> Title: OPERATIONS COORDI TOR Date: 3 / 16 / 99 <br /> Do Not Write Below This Line <br /> R.E_i-i.S. Application Approval: Date: /Zo/ Expiration Date: ZI <br /> EH4502 10.43-96 Date Paid 3 /l?— / 5'S Cash or a 11-5p(o - (circle) Acct �' ' <br />