Laserfiche WebLink
J aquin County Public Health Sery , <br /> Environmental Health Division <br /> Medical Waste Management Prcgram <br /> i <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Ac:', tate Following <br /> conditions must be met <br /> The generator or health care professional generates less than 20 pounds of medicat 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 /> ti- Medica! Waste Management Ran 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 /> register pursuant to Chapter 4. <br /> PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH SG7 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 /> i <br /> Medical Waste Hauler information <br /> ❑ Newfil'�Renewal <br /> Medical Office/Business Name:. J4 , M /l' Ad,W (*ow <br /> Medical Office]Business Address: c rn� ret <br /> Stale: 77p. Code: <br /> City: �eJe r Phone -#F .?o - 67 Cy7� <br /> Contact Person. ; <br /> Storage Facility Name: T, z-�S <br /> Storage Facili Add ess: r `� <br /> State: Trp Cade: 2f-206,1 <br /> City: � <br /> permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: r State: QA-- Zip Cade: <br /> City: <br /> ist all employee names and titles authorized to transport the medical waste. If not enough space, attach information- <br /> Se l�[ Grp! True: <br /> 1- Name:,_ Title: <br /> 2- Name: Title: <br /> 3- Name: <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transpert{ng medical waste. in <br /> addition, all copies of medical waste records shall be kept on fife at se raters or health pre professional's facility. <br /> Applicant Signature: <br /> Tide: `kms k-v(e Date: /•� I U 102r <br /> Do Not Write Below This Line <br /> 2.E.H.5. Application Approval <br /> Date: I I Expiration Date: . 1 <br /> EH4502 10-03-36 <br /> Date 4Paif� 1 / 1 D Cash or 1/D (circle) Acct <br />