Laserfiche WebLink
San Joaquin County Public Health Services IP4 <br /> Environmental Health Division p� <br /> Medical Waste Management Program <br /> N 2z 1998 <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EX4Q,�IoU� <br /> "4M Alf) �c`r"�y�F o ty <br /> To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste ManagementAa g4�04 F,pllowing <br /> conditions must be met: <br /> The generator or health care professional generates less than 20 pounds of medical waste per week, transports 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 or a small <br /> 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 to <br /> register pursuant to Chapter 4. <br /> PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH $67 FEE TO: 1/0 7/1J P <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> Cd/New ❑ Renewal <br /> Medical Office/Business Name: �1. SrGU <br /> Medical Office/Business Address: co-010 <br /> City: 6j71 State: CA Zip Code: LD <br /> Contact Person:___ 6l N l4 Phone #: (XA u 3to� <br /> Storage Facility Name: b(A 5 kU <br /> Storage Facility Address: <br /> City: 6T Cy\ State: 09 Zip Code: K LO� <br /> Permitted Treatment Facility Name: - <br /> Pey itte�� !e� ���t Facility Address: <br /> Cit : State: Zip Code: <br /> List all employee ames and titles authorized to transport the medical waste. If not enough space, attach information. <br /> 7 <br /> 1- Name: i .�' 6Vr,1wU"6 —NIA <br /> Nl G Title: s <br /> 2- Name: I C ' I ! - Title: <br /> 3- Name: L 61A, Title: <br /> A copy of this exemption and tra I ocument shall be in employee'!i possession at all times while transporting medical waste. In <br /> addition, all copies of medic I a e/l ords shall bo kept on file at genorator's or health care professional's facility. <br /> Applicantgna urh J <br /> Title: Date: / / 74 <br /> Do Not Write Below This Line <br /> R.E.H.S. Application Approval: Date: / / Expiration Date: / / <br /> EH4502 10-03-96 Date Paid /a? / V Cash oreck 4809 (circle) Acct`7� �.c� <br />