Laserfiche WebLink
SAAR AQliIN COUNTY PUBLIC HEALTOERVICES <br />ENVIRONMENTAL HEALTH DIVISION 0 D <br />Medical Waste Management Program <br />APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />"Limited Hauling Exemption!' pursuant to the "Medical Waste <br />To qualify fora Lunited Quantity g p <br />Management Act", you are required to meet the following conditions: <br />1- Your medical office/business generates less than 20 pounds of regulated medical <br />waste per week. <br />2- Your medical office/business transports less than 20 pounds of regulated medical <br />waste at any one time. <br />3- Your medical office/business lmaintains records o airy regulated medical waste <br />transported offsite for treatment and disposal, including the quantity of the waste <br />transported, the type of the waste transported, the date the waste was transported, <br />the name of authorized person that transported the waste and the destination of the <br />waste. <br />j'' <br />PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH $67 APPLICATION FEE <br />TO: <br />San Joaquin County Public Health Services <br />Environmental Health Division <br />P.O. Box 2009 <br />Stockton, CA 95201 <br />Medical Waste Hauler Information <br />Medical Office/Business Name: Stockton Fire Department <br />Medical Office/Business Address: _425 N El Dorado St <br />City: Stockton State: Ca Zip Code: 95202 <br />Contact Person: Carl Eck Phone #:944-8528 <br />Permitted Treatment Facility Name: Permit #: <br />Permitted Treatment Facility Address: <br />City: State: Zip Code: <br />Please list employee names and titles authorized to transport the medical waste. <br />1- Name: See attachment Title: <br />2- Name—Title: <br />3- Name: Title: <br />If transporting medical waste to a permitted storage facility for consolidation purposes or if veterinarian <br />or home health care nurse transporting medical waste back to own facility, please complete the following: <br />Storage Facility Name: LL14 Permit #: <br />Storage Facility Address:_ N/l4 <br />City: State: Zip Code: <br />A copy of this exemption and a tracking document containing the information above shall be in <br />employees possession at all times while transporting medical waste. In addition, all copies of <br />medical waste records shall be keEt on file at cility. <br />Applicant Signature: ( r, �� Title:Date: <br />C <br />R.E.H.S. Application Approval: &,01 Date: ' / - 3 <br />EH 45 02 12-2-91 <br />