COMPLIANCE INFO_1983-2005 - Laserfiche WebLink

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FROM � FAX NO. �y. 27 2005 03:17PM P2 SAN JOA UIN Q COUNTY ENVUtONMENTAL 11EA1,TH DhPARTMFNT 304 Fast Weber Avenue,3r'floor, Stockton, CA 95202,2708 o o �� Telephone:(209)468.3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd -�•jk APPLICATION FOR ,A LIMITED QUANTITY HAULING EXEMPTION To qualify fora"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management Act" the conditions must be met: #olIowing The generator or health care professional generates less than 20 pounds of medical waste than 20 pounds of medical waste at any one time,maintains a tracking document ptusuant to M P transport a° gess generator or parent organization has on file one of the following; l. MedicalWast'.Management Plan if the generator or parent organization is a large . or a small quantity generator required to register pursuant to Chapter 4. S quantity generator 2. Information Document if the generator or parent organizatiomall quantity generator not re to register pursuant to Chapter 4, n is a saired q Please complete the information below and rnai(with$70.00 fee to: San Joaquin County Environmental Health Department Medical Waste Management Program 304 East Weber Avenue,31d Floor, Stockton,CA 95202 Medical Waste Hauler Information C7 New Renewar Medical OffiCe/13usitless Name: Medical Offiae/Business Address: P AN JOA UT 0 N Y E R. BOX 1499 / 500 WEST HOSPITAL ROAD FRENCH CAMP, CA 95231 Contact Person: City State Phone Number: CHUCK PEEK Zip Code .209) 468-6166 Storage Facility Name: Storage Facility Address- Satne City State Permitted Treatment)Facility Name: SAN JOA UIN GENERAL H g Zip Cods Permitted Treatment Facility Address: 50 . WEST HOSPITAL ZZpAp FRENCH CAMP, CA 95232 City CA List all employee names and titles authorized to transport the medical waste(If i2lore than 3 Zip Code 1.Name: CE V, ,attach info); 2.Name: JOSE LOPEZ Title: oU g 3. Name: ZACK HERNANDEZ Title: tt if Wo IT E-P A copy Title: of this exemption and a tracking document shatj be in em to 'r addition,all Copies of medical waste re or shall be kept on file at gepea ator's 4r health care professional's faefili P t'ee's possession at all times while transporting medical w�� In Applicant Signature: � ty. Title: FACILITIES MANAGER Date: DON T WRI E BELOW THIS LINE R.E.H.S. Application Approval: Expiration Datc: / 1 n�batc Paid: I 3 Date: 121jr' EMD a5 p2.00t `sL1 1/�Cash or Check#i: 60fl1 eived B f 0i!/2oD3 y: L CCJJ��"