Laserfiche WebLink
SAN JOAQUIN COUNTY <br />a ENWONMENTAL HEALTH DEPRTAT PAYMENT <br />DECEIVED <br />304 East Weber Avenue, 3'd Floor, Stockton, CA 95202-2708 <br />P (209) 468-3420 • Fax: (209) 468-3433 . Web: www.co.san-joaqum.c . a.us/ehd DEC 3 U 2003 <br />9CIr <br />APPLICATION FOR A LIMITED QUANTITY HAULING EXEMIP� ENVIRONMENTAL <br />COU Tr <br />�� T HEALTh( 'RAMPNowing <br />To qualify for a "Limited Quantity Hauling Exemption p to the Medical Waste Management Act , <br />conditions must be met: <br />The generator or health care professional generates less than 20 pounds of medical waste per week, transport 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 <br />or a 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 <br />to register pursuant to Chapter 4. <br />Please complete the information below and mail with $70.00 fee to: <br />San Joaquin County Environmental Health Department <br />Medical Waste Management Program <br />304 East Weber Avenue, P Floor, Stockton, CA 95202 ` <br />Medical Waste Hauler Information` <br />E] New 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 Treatment Facility Address: <br />City State c ip s vuc <br />C/0-444 C) P k� <br />_C2d�,, 9Y3-3F�3ca - <br />r'S�.•d 2.. <br />City State Zip Code <br />City state Glp \-Vuc <br />List all employee names and titles authorized to transport the medical waste (If more than 3, attach info): <br />3. Name: <br />Title: <br />Title. <br />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 file at generator's or health care professional's facility. <br />Applicant Signature: Date: <br />Title: ��o <br />DO N T WRIT BELOW THIS LINE <br />R.E.H.S. Application Approval: Date: <br />Cash or C eck 5 Received BY: <br />Expiration Date:/ J /Date Paid. <br />EHD 45-02.001 <br />10/7/2003 <br />