COMPLIANCE INFO_1991-2019 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY EIWONMENTAL HEALTH DEPAR TP.°rMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.or 1008 �.: APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIO1 AN i Ai UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT" 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 l,�-. is x Q1 t vii 600 East Main Street, Stockton, CA 95202-3029 j Medical Waste Hauler InformatiPia;l,a;Lr�, Vi ❑ New EkRenewal Medical Office/Business Name: Delta Blood Bank, Medical Office/Business Address: 65 North Commerce Street Stockton CA 95202 City State Zip Code Contact Person: Elavda nodesta Phone Number: (209) 943-3830 ext. 220 Storage Facility Name: Delta Blood sank Storage Facility Address: 65 North Cominerce Street Stockton CA 9.5202 City State Zip Code Permitted Treatment Facility Name: stericycle, Inc. Permitted Treatment Facility Address: 4135 W. Swift Ave . Fresno CA 93722 City State Zip Code List all employee names and titles authorized to transport the medical waste (If more than 3, attach info): 1. Name: SEE ATTACHED Title: 2. Name: Title: 3. Name: Title: A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In addition, all copies of medical waste records shall be kept on file at generator's or health care professional's facility. Applicant Signature: Date:. ' 4 Title: Compliance Officer DO NOT WRI E BELOW THIS LINE R.E.H.S. Application Approval:, Date: / Expiration Date: �_/ / Date Paid: �/ 4D /(�, heck Received By: EHD 45-01