Laserfiche WebLink
Co% SAN JOAQUIN COUNTY <br />EN*NMENTAL HEALTH DEPART <br />Py <br />600 East Main Street, Stockton, CA 95202-j2 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: ww s g/eh r.Ur, <br />�1Q <br />APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTI6 , tr,coij <br />NTy <br />TAL <br />To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Act", the o1a�i�ig <br />conditions must be met: <br />The generator or health care professional generates less than 20 pounds of medical waste per week, transport 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 <br />or a 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 <br />to 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 <br />Medical Waste Management Program <br />600 East Main Street, Stockton, CA 95202-3029 <br />Medical Waste Hauler Information <br />❑ New XRenewal n <br />Medical Office/Business Name: <br />1`E' ✓'/�^�ti e �'P j `%off K�o� <br />Medical Office/Business Address: % 3 -7 1 Ly e-6 4 4,� e _ <br />S .. O C ttfyN C e -t 2/c) <br />City State Zip Code <br />Contact Person: jckl r- I S <br />Phone Number: 1,09- <br />Storage <br />09- <br />Storage Facility Name: <br />Storage Facility Address: <br />Permitted Treatment Facility Name: <br />Permitted Treatment Facility Address: <br />City State Zip Code <br />City State Zip Code <br />List all employee names and titles authorized to transport the medical waste (If more than 3, attach info): <br />1. Name: _ rz l A�lJ Title: 'Ne, « (its e i iti eS 5 <br />2. Name: Ej6N ne- 4-4 -t T -e V AJC' S Title: L-VP�Alr PCS e, r <br />3. Name: Title: Ce -,i, E ° 00. <br />+ L401 <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 waste <br />,,regords shall be kept on rile at generator's or health care professional's facility. <br />Applicant Signature: <br />Title: CVS %I/1 i4Nla-� �✓ <br />Date: f I,?—?,•re) <br />DO NOT WRITE BELOW THIS LINE <br />R.E.H.S. Application Approval: W4 V1x.���ulM� Date: /' /C)3 /j 1 <br />Expiration Date: It- /�/ (( Date Paid: / �c1 / � b 4Qaslror Check #: Received By: t (f <br />EHD 45-01 <br />