Laserfiche WebLink
Jan, 7, 2013 228P San Joaquin County 9W '°N W t :t �IOZ° •L 'u'er aw11 pansa <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT i <br /> 1868 East Hazelton Avenue,Stockton, CA 95205-6232 <br /> t` (209)468-3420 Fax;(208)464-0138 Web:www,sj9ov.org1ehd <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for a'Llmit,~d Quantity Hauling Exemption" pursuant to the"Medical Waste Management AcV,the following <br /> conditions must be met: <br /> The generator or healthcare professional generates less than 20 pounds of medical waste per week,transports less <br /> thein 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 <br /> 1. medical Waste Management Plen 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 /> I <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 r <br /> Medical Waste Management Program o 1 <br /> 1868 East Hazelton Avenue, Stockton. CA 962OM232 R0�1� <br /> MegjRal Waste Hauler Information <br /> I <br /> D New VRenewal q� <br /> Medical officelBusiness Name: co ar. `v <br /> Medical office/Business Address <br /> City $tete Zip code <br /> Contact Person: <br /> Phone Number: `� <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> tarty State ,i;lp Code }2� <br /> ' Permitted Treatment Facility Name: - ��� CoQ( obo�N6 ,� QHS w <br /> Permitted Treatment Facility Address: <br /> city State Zip code <br /> List all employeemes end hies authorized to transport the medical waste (if more than 3, attach into): <br /> 1, Name: 10,E �.� Title: y <br /> 2. Narno: Title: <br /> 3. Name: Title: <br /> A copy 01 this exemption and a trae)anq doaUnwnt shall be in arnpioyWo poaseseon at all tlmes while transporting medic■l wasu, fn addrtiar+,all copf"or <br /> medical waste records shall be kept an MCI[panaratol's or health care profoasloncil's foclllty. <br /> Applicant Signature: Date: <br /> Title: <br /> DO NOT WRITE BELOW T141S LINE <br /> RENS Application Approval: 4 .�- ,9it„r Date: <br /> (ration Dat®, I ' Date Paid'� f, Cash or CReck 0:� Received By: <br /> �� i <br /> 4b01&V12APPLICATION MR A LIMIM QUANTITY MULINO EgeM?TION <br /> T060/T000 Z MOSV860Z XV,3 Rd VV:S CTOVLO/T <br />