Laserfiche WebLink
D <br />0 SAN JOAQUIN COUNTY I <br />ENVIRONMENTAL HEALTH DEPARTMENT 2 <br />600 East Main Street, Stockton, CA 95202-3029 ENVIRON AIIIALTH <br />(209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd ENAWWA R pfim <br />PERMIT/SERVICES <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 />Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a <br />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 to <br />register pursuant to Chanter 4. <br />Please complete the information below and mail with $77.00 fee to: <br />San Joaquin County Environmental Health Department a: " <br />Medical Waste Management Program <br />600 East Main Street, Stockton, CA 95202-3029 <br />Medical Waste Hauler Information <br />❑ New <br />Renewal <br />Medical Office/Business Name: <br />Medical Office/Business Address <br />Contact Person: <br />Phone Number: <br />Storage Facility Name: <br />Storage Facility Address: <br />Permitted Treatment Facility Name: <br />Permitted Treatrnent Facility Andress: <br />f S P Aa r rte jq �v� ��- ��o c -�6 &•' <br />•;, v„ - <br />City ,0 O AJ State 0— Zip Code <br />�D 9 �/ <br />1A i <br />City o cJfC4'oA1 State Ca Zip Code <br />city Mate up Loae <br />List all employee names and titles authorized t transport the medical waste (If mor than 3, attach info) <br />1. Name: 06 N e I/ e 3 1' De'E'✓ Title: Z7n-►-�1at(Pe "— 4L 1W n/Gw s� <br />2. Name: 4j rA r r Title: 3 Df u (C a1^t octN eI <br />3. Na e: en f rn- & �l� Title: d, e Lt, k � eyt°55 ML�v 'Pte' <br />'1' T�7C,`-1='irrolc15 �v�A)4 Corr] j; rr&go� <br />A copy of this exempt on and a tracking do ument shall be in employee's possession at all times while transporting medical waste. In addition, all copies of <br />medical waste records shall be kep n file at generator's ophealt care professional's facility. I <br />Applicant Signature: ; Date: <br />Title: 14`_ i/ AAJ 1461. r <br />DO NOT WRITE BELOW THIS LINE <br />REHS Application Approval: CAL-., Date: 6/ Os / - <br />v <br />Expiration Date: �2 / 3� /l2- Date Paid: Z / Zz/ I I Cash or 1h 9- <br />k Received By: <br />EHD 45-01 11/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION <br />1Z <br />t <br />