Laserfiche WebLink
Qan Joaquin County Public Health #ices <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> APPLICATION FOR 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 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 /> 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 /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> Cl New 0 Renewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: <br /> City: State: Zip Code: <br /> Contact Person: Phone 4! <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> City: State: Zip Code., <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: <br /> City: State: Zip Code: <br /> List ail employee names and titles authorized to transport the medical waste. If not enough space, attach information. <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 ftwnporting medical waste. In <br /> addition, all copies of medical waste records shag be kept an file at generatoes or health care professionars facility. <br /> Applicant Signature: <br /> Title: Date: <br /> Do Not Write Below This Line <br /> R.E.H.S. Application Approval: Date: L_/ Expiration Date-.— <br /> -96 Date Paid Cash or Check a (circle) A <br /> EH4502 10-03 cct-------- <br />