Laserfiche WebLink
SAN JOAQUIN COUNrV <br /> ENVIRONNMENTAL HEALTH DEPARTMENT FILE <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> _:.,:.:,.•P Telephone: Py <br /> {209)468-3420 Fax:(209)468-3433 Web:www,sjgov.org/ehd <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 er week, <br /> than 20 pounds of medical waste at any one time,maintains a tracking document pursuantto Chapter the <br /> port ess <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 fee to: <br /> ` San Joaquin County Environmental Health Department PAYMENT <br /> Medical Waste Management Program RECEJVED <br /> 600 East Main Street, Stockton, CA 95202-3029 AUG 1 7 <br /> Medical Waste Hauler InformationSAN ZOd9 <br /> , New E]Renewal E�ROUfNCOUN-Y <br /> y�c aEPAFiM Nr <br /> Medical Office/Business Naugle: <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: c <br /> Permitted Treatment Facility.Address: <br /> City State Zip Code <br /> List all employee names and titles authori ed 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 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 /> R.E.H.S. Application Approval: Date: ll <br /> Expiration Date: 1 Date Paid: S I rl I C•tts Check# L-0%Lk% Received By: <br /> EID 45-01 <br /> 11/19/08 <br />