Laserfiche WebLink
RECENEDD S,�oagciin County Public Health SerEnvironmental He;3ith Division �. <br /> JAN 0 9 2002 Medical Waste Management Program <br /> BVIRUNMElPM`TION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> . <br /> PERMIT/SERVICES <br /> To qualify for a "Limited Quantity Hauling Exemption" pursuant t4 the "Medical Was' Management Ac:', the rollawing <br /> conditions must be met <br /> generator or health car.. prones <br /> Flee <br /> 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 small <br /> quantity generator required to register pursuant to Chapter 4. <br /> 2- <br /> Information Document if the generator or parent organization is a small quantity generator not required to <br /> nt to Chapter 4. <br /> register pursuant p . <br /> f PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH S67 FEE TO: <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> 0 New a Renewal <br /> Medical Office/Business Name: S c <br /> Medical Office/Business Address: 770 G/� KC S te: �j _gyp Cade: S!G <br /> City: GJAu✓ClT u���,� - — Phone 'tr. zs s2-94Gs <br /> Contact. Person: ./,4ck <br /> Storage Facility Name: <br /> Storage Facility Address: / 67 <br /> City: State: CIA Zip Cade: Sof S� <br /> C/lJL-(.�!! <br /> Permitted Treatment Facility Name:_'113 <br /> Permitted Treatment Facility Address: 5135 irJ-SuJ1Gi AIG - <br /> City:� F/'cs,✓� State: CA -Zip Cade: <br /> list all employee names and ales authored to transport the medical waste. If not,enough space, attach information. <br /> �- Name: J G, A�— �rJl�ClL Ttle: l"I�If�T/�� <br /> 2- Name: SirAh: ►/� 4�=i 7_ Title: <br /> f 3- Name: - - Title: <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times wltiie transporting medical waste. In <br /> lt de kept an file at generator`s or health care prafessionars facirity. <br /> addition, all copies of medical waste records sha <br /> Applicant Signature: - <br /> Title• � -S Date: <br /> Do Not Write Below This Line <br /> 4.E.H.S. Application Approval: <br /> Date r / /02-Expiration Date-:/.. <br /> EH4502 10-03-96 Date Paid 1 I q / Oa, ash or hec.< - r!3 W (circle) Acct <br />