Laserfiche WebLink
° <br /> . . <br /> pAYMENT <br /> c�u°`-^~ <br /> n� | ' <br /> ��� �����8� ������ <br /> SAN �� <br /> ENVIRONMENTAL HEALTH DEPARTMENT DEC 2 6 �� <br /> ��� <br /> 1OG8East Hazelton Avenue, Stockton, CA 95205-6232 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> CZOS\488-3420Fax: (2OQ)4G4'O13OWeb.vmmwv. gov.org/ehd HEALTH <br /> APPLICATION FOUR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for a"Limited Quantity Hauling Exemption" pursuant to the"Medical Waste Management Act', the following <br /> conditions must bamet: <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 orparent organization has onfile one ofthe 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 toregister pursuant toChapter 4. <br /> 2. Information Document if the generator or parent organization is a small quantity generator not required to <br /> register pursuant hoChapter 4. <br /> Please complete the information below and mail with $77.00 fee to: <br /> San Joaquin County Environmental Health Department APP <br /> ROV <br /> Medical Waste Management Program <br /> 18O8East Hazelton Avenue Stockton, <br /> ' <br /> O New �Renewe| <br /> &0odioeKK]f5ce/Bus[nees Name: <br /> Medical C)Oioe/BuaineuaAddnaso <br /> S�t�ae <br /> Contact Person: <br /> Phone Number: 15 3 <br /> Storage Facility Name: � ' '''—' ` �--~_ ' `` ~~~�~— . <br /> Storage Facility Address: <br /> Permitted Treatment Facility Name: -� <br /> Permitted Treatment Facility Address: <br /> city State <br /> List all employee the nnedioa|vvoute (If more than 3, ataoh info): <br /> 1. Nanne� ~��£�- Tit*: <br /> ---� Title: <br /> 2. Name: � <br /> ---��� <br /> 3. Name: Title: <br /> Acopy vrthis exemption andatracking document shall uei auall times while transporting medical waste. In addition,all copies m <br /> medical waste records shall uokept vnfile atooneramrov,health care professional's facility. <br /> ApplicaV Signature: Date: <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: �1� - Date: �7,/3L/A&, <br /> Expiration Date: - Paid: 1:1-/2-LL[2L-Cash oi���eck �'iLw—a/Received By: <br /> APPLICATION FOR ALIMITED QUANTITY HAULING EXEMPTION <br />