Laserfiche WebLink
i <br />0 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />(209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />REcE VED <br />,yEc _ 7 2012 <br />COUN I" <br />SAN NV JOA XL <br />SENT <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 <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 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 APPROV <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 I <br />Medical Waste Hauler Information <br />f <br />❑ New Renewal <br />3 <br />r; <br />Medical Office/Business Name: Delta Blood Bank <br />Medical Office/Business Address 65 North Commerce Street <br />Stockton, CA 95202 <br />City State Zip Code <br />Contact Person: Elayda Podesta <br />Phone Number: 09 943-3830 x220 <br />Storage Facility Name: Delta Blood Bank <br />Storage Facility Address: 65 North Commerce St. Stockton, CA 95202 <br />City State Zip Code <br />Permitted Treatment Facility Name: <br />Permitted Treatment Facility Address: 4135 w Swift Au <br />Fsesnn., (ag37-)2 <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: SEE ATTACHED Title: <br />2. Name: Title: <br />3. Name: 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 addition, all copies of <br />medical waste records shall be kept on file at generator's or health care professional's facility. <br />Applicant Signature: <br />Title: <br />Date: le- 21-IZ <br />DO NOT WRITE BELOW THIS LINE <br />REHS Application Approval: Q d �-�- l / Date: f / /fes <br />�� <br />Expiration Date: / / ) Date Paid: l-2-•-/ '7 / 12_ -Cash o heck �o9S `7 Received By: Mi L <br />EHD 45-015/2/12 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />