Laserfiche WebLink
EASAN JOAQUIN COUNTY ! j <br /> RONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 FEB 1 5 -2008 <br /> P Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd tt T <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTI '''! USERVIC-Es <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 <br /> Medical Waste Hauler Information <br /> Q New Renewal <br /> Medical Office/Business Name: <br /> �( iC <br /> Medical Office/Business Address: <br /> Ci State Zip Code <br /> Contact Person: <br /> Phone Number: <br /> X Storage Facility Name: --- ��( t � S <br /> X Storage Facility Address: <br /> City State Zip Code <br /> KPermitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: <br /> X City X State x Zip Code <br /> List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): <br /> 1. ILA ( Title: <br /> 2. Name: Title: <br /> 3. Name: =UTitle: VQ <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. �Q <br /> Applicant Signature: ; _ Date: <br /> Title: L 0 <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: <br /> Expiration Date: Date Paid: D Cash or Check#:�M;1(0562Received By: � <br /> EHD 45-01 <br />