Laserfiche WebLink
S Joaquin County Public Health Sces <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Act", the following <br /> conditions must be met: <br /> The generator or health care 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- 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 $67 FEE TO: <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> P.O. Box 388 <br /> Stockton, CA 95201-0388 <br /> Medical Waste Hauler Information <br /> C3 New V Renewal <br /> Medical Office/Business Name: I e a .�ea�-1 (�are. _ <br /> Medical Office/Business Address: °1 `I rJ , Center S+ <br /> City: S+ocic. f) tate: CO Zip Code: 95-;;Zv;. <br /> Contact Person: 5 f12R C770b w 0 h)P Phone #: <br /> �➢ torage Facility Name: 4-, o_ talc <br /> Storage Facility Address: 4 rec I ss i <br /> City: 'S-i'coC V_-To ) State: CA Zip Code: 9Sa0� <br /> Permitted Treatment Facility Name: I C <br /> Permitted Treatment Facility Address: 91 St. <br /> City: *o c(f_+0-N_ State: CA Zip Code: 75a z, <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> 1- Name: Pm r .a e P Title: A)? <br /> 2- Name: s an F Title: A)JO <br /> 3- Name: S Title: <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 ste records shall be kept on file at generator's or health care professional's facility. <br /> Appliant Signature: _ G <br /> Title: - Date: /Z/ >b / 5� <br /> Do Not Write Below This Line <br /> R.E.H.S. Application Approval: 4-,M, Date: /I I piration Date: j / 198 <br /> Ei4502 10-03-96 Date Paid l oZ / a?3 ! G Cash tChec # llS (circle) Acct, <br />