COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

San Jo*ronmental n County Public Health Services ~� Health Division 0 Medical Waste Management Program 1 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Act', the following conditions must be met: The generator or health care professional generates less than 20 pounds of medical waste per week, transports less than 20 pounds of medical waste at any one time, maintains a tracking document pursuant to Chapter 6, and the generator or parent organization has on file one of the following: 1- Medical Waste Management Plan if the generator or parent organization is a large quantity generatcr or a simail quantity generator required to register pursuant to Chapter 4. 2- Information Document if the generator or parent organization is a small quantity generator not required to register pursuant to Chapter 4. PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH $67 FEE TO: San Joaquin County Public Health Services Environmental Health Division Medical Waste Management Program P.O. Box 388 Stockton, CA 95201-0388 Medical Waste Hauler Information New I � Renewal w Medical Office/Business Name: 01FLIA fel O 4 c, 1 C-/q- L it 1 Medical Office/Business Address: City: 0 t State: LiAZip Code: 17L5 3-4 40 Contact Person: cyC-4,�LiS i'- S Phone % -..5c�--I Storage Facility Name: L m"77D/777 Tt >✓777 C7 L- G Storage FaciliAddress: I ( 1�/ / _lc-- S: City: 1 o D t State: L t ip Code: �f- Permitted Treatment Facility Name: 7A-T' 7 moi✓[/i R' o A✓iLt Permitted Treatment Facility Address: �L- ?!� f-}1�1f- S7—, City: n 'A A4 J „ ,9 State: A= Zip Code: 52 o List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. 1- Name: . Kc it e S '--'D t Title: r� 2- Name: Title: 3- Name: 1.G iZs' S xy L l S Title: A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. in addition, all copies of medical waste ords shall be kept on file a enerator's or health care professional's facility. Applicant Signature: Title: /i' �f 7 Date: /;2--/ Do Not Write Below This Line R.E.H.S. Application Approval: dal, Date: xpiration Date: EH4502 16-03-96 Date Paid IQ/ /6 / 96 Cash or (:�h #03'VOA y (circle) Acct