Laserfiche WebLink
E ONMENTAIe HEL�LTH DEPARTIWT <br /> 304 East Weber Avenue, 3�'Floor, Stockton,CA 95202-2708 <br /> P. Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> C�POR� <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for a"Limited Quantity Haiiling 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 medicalwastell per week,transport less <br /> than 20 pounds of medical waste at any one time,maintains a trackin u to 6 and the <br /> generator or parent organization has on file one of the follower► .rr 4. <br /> 1. Medical Waste Management Plan if the generator _. erator <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 rem <br /> to register pursuant to Chapter 4. <br /> hlease 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, 3'd Floor, Stockton,CA 95202 <br /> Medical Waste Hauler 1,nformation <br /> Q New ❑ Renewal _ <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: <br /> City r Stat Zip Code <br /> Contact Person: <br /> Phone Number: S <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 all employee names and titles authorized to transport the medical waste(If more than 3,attach info): <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 transporting medical waste. In <br /> addition,all copies of medical waste records shall be ke t on file at generator's or healthcare professional's facility. <br /> Applicant Signature. Date: <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: <br /> Expiration Date: / / Date Paid: JA /E _/PY_Cash or eck ' Received By: <br /> EHD 45-02-001 <br /> 10n12003 <br />