Laserfiche WebLink
au SAN JOAQUIN COUNTY <br /> �o �o <br /> 2 ' E*ONMENTAL HEALTH DEPARTIVZIVT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> • �c:, `P Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> 4��FOR <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,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$72.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program : - <br /> 600 East Main Street, Stockton,CA 95202-3029 000�, SAN r .> ��CMedical Waste Hauler Inform `-AJ,1r?D��'/;i ME <br /> 1ELi ,� =irivlfl7 <br /> ❑ New XRenewal <br /> Medical Office/Business Name: 5;rj r X-T o , <br /> Medical Office/Business Address: L12-5, . 6,c <br /> City State Zip Code <br /> Contact Person: 2... <br /> Phone Number: -,'9S <br /> Storage Facility Name: S-t-oc.Ktuo t=,,r-c <br /> Storage Facility Address: 110 7, nnr7�_. <br /> City State Zip Code <br /> Permitted Treatment Facility Name: c <br /> Permitted Treatment Facility Address: t -15 <br /> F1,fn 0 C'orr3 r Pr CI S 7 4 Z <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 /> I. Name: - , ' o.,-,� ---c,z- Title: .0 •)- -r e�/,-- <br /> 2. <br /> ,=2. Name: -5 ;r �� ,v o wA L-D Title: /s R-r6;Z <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 file at generator's or health care professional's facility. <br /> Applicant Signature: -;�-- _ Date: ZL3-/o•;L- <br /> Title: o,,� cam• <br /> DO N T WRIT ELOW THIS LINE <br /> R.E.H.S. Application Approval: _ Dater-- /-�L/-o� <br /> Expiration Date: Date PI: lgklQ7-- Cash o eck :103��/ Received By: <br /> EHD 45-01 <br /> 10/02/07 <br />