BILLING - Laserfiche WebLink

Home Browse Search

�a SAN JOA UIN COUNTY Pqj�MIEN-r `. Q RECEjVEd f ( nD DI,,RONMENTAL HEALTH DEPART-,..,,NT 600 East Main Street, Stockton, CA 95202-3029 DE 2 8 2009 le one: 20 468-3420 Fax: 209 468-3433 Web:www.s ov.or /ehd .. �� SAN JOAQUIN coUt4-y \t o ENVIRONMENT/U„ APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTI Lr�0EPAFa,, n r To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management Act", the following conditions must be met: The generator or health care professional generates less than 20 pounds of medical waste per week, transport less than 20 pounds of medical waste at any one time, maintains a tracking document pursuant to Chapter 6 and the generator or parent organization has on file one of the following: 1. Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a small quantity generator required to register pursuant to Chapter 4. 2. Information Document if the generator or parent organization is a small quantity generator not required to register pursuant to Chapter 4. Please complete the information below and mail with $77.00 fee to: San Joaquin County Environmental Health Department Medical Waste Management Program 600 East Main Street, Stockton,CA 95202-3029 / Medical Waste Hauler Information [�fj ❑New Renewal Medical Office/Business Name: _ . ,jOSQR� _WZ&W-' A u e� Medical Office/Business Address: 1QC'O M_ aA; emyx- gh _City State Zip Code Contact Person: A&ALA V e, Phone Number: o f-- m Storage Facility Name: 1 E&QLSA N.,Ai"- Storage Facility Address: _Nkn N. CaLVYSos 3 pow - City State Zip Code Permitted Treatment Facility Name: ':�N, �a 'S M QQA& k v- Permitted Treatment Facility Address: (eCC3 N- 0i V'A ick '�KVL.�.� _2&V V', Ek, cls jl City State Zip Code List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): P Q 1. Name: 50-AojC�-W-Q,1,kk Title: 2. Name: Title: 3. Name: Title: A copy of this exemption and a tracking document shat in employee's possession at all times while transporting medical waste. In addition,all copies of medical waste records shall be a on file at generator's or health care professional's facility. Applicant Signature: Date: 1 - /( Title: C� �v torr 9r c�y� Su4b�� u�Sic � 1 DO NOT WRITE BELOW THIS LINE R.E.H.S. Application Approval: -�, ,_ ,. �` Date: g j e l 1 c Expiration Date: 2- A i / I G Date Paid: Cash rChe :(:�b 1k Received By: ERD 45-41