Laserfiche WebLink
Y Saaquin-County Public Health Servi <br />Environmental Health Division <br />Medical Waste Management Program <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 small <br />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 $67 FEE TO: <br />San Joaquin County Public Health Services <br />Environmental Health Division <br />Metlical Waste Management Program <br />304 E Weber Ave <br />Stockton, CA 95202 <br />O New Renewal <br />Medical Office/Business <br />Medical Office/Business <br />City: Sive <br />Contact Person: - <br />Medical Waste Hauler Information <br />Pe 46L L 66 <br />N <br />ode' <br />e 6-5 `,? 3 <br />Storage Facility Name: UG/TR LY006C OCIV1,11".L006 <br />Storage Facility Address: G 5W, <br />State: 0/1- Zip Code: 9 -5 -?O <br />City: <br />Permitted Treatment Facility Name: 6 F'I- / <br />Permitted Treatment Facility Address:�-r <br />At S �3 <br />City:.„ State: -7"17y— Zip Code:? y- <br />List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br />Cit7�Lr <br />1- Name: 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 <br />addition, all copies of medical waste records shall be kept on rile at generator's or health care professional's facility. <br />Applicant Signature: L"�} <br />Title: � lot <br />Do Not Write Below This Line , <br />Date: 22 /:2-/ / `�' <br />R.E.H.S. Application Approval:' c 1. _Date: 17/�` Expiration Dater% <br />EH4502 10-03-96 Date Paid �� / aa/ 98 Cash or Check # 3830 Z (circle) Acct �J <br />