Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> 4 E-►.,.,,ZONMENTAL HEALTH DEPARTaT OPY <br /> 600 East Main Street, Stockton,CA 95202-3029 . <br /> .c P Telephone: (209)468-3420 Fax: (209)468-3433 Web: www.sjgov.orglehd <br /> DEC 2 �U <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTI4?A,;rJAQUiN <br /> ENVIHQNM[ 3L <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the "Medical Waste ManagemenPMVtitfvElowing <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 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 /> ❑New P4 Renewal <br /> Medical Office/Business Name: Ul5om l'ti1nW6Ylc-S <br /> Medical Office/Business Address: ch Y W <br /> City State Zip Code <br /> Contact Person: Mag e- Chcvall t r <br /> Phone Number: <br /> Storage Facility Name: ` 'M 9tS _?,O_awe <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: ,Ki C CA C, <br /> Permitted Treatment Facility Address: 1'345 per' Of <br /> _ n L-ea r4,r D eq q 4 sS <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: LUVItc. 04%(041e- Title: _N.n ro n acr <br /> 2. Name: Sala n► e- LLkar-eA Title: <br /> 3. Name: '%42 fe.t,0 Title: M <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: L,-M A XX G6� Date: a " I'o <br /> Title: �.e j e- M Yloa cl <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: _�--9� -�` _Date: &J/ E) <br /> Expiration Date: I?_1_._lam Date Paid: �`�IZ`� / 1 to Gash a Check# `{j °33 Received By: <br /> EHD 45-01 <br />