Laserfiche WebLink
San Juin County Public Health Servicd <br /> �a .') . = I► Ah . FIEALI Il <br /> nvironmental Health Division 1, ,�g,irc <br /> Medical Waste Management Program <br /> ,.1AENA l k v 03 OCT -7 AM Ile 57 <br /> srPPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> f fir M iteddQuantity Hauling Exemption" pursuant to the "Medical Waste Management Act", the following <br /> ions must be met <br /> I e generator or health care professional generates less than 20 pounds of medical waste per week, transports less <br /> ;han 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 organiza4an 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 tqpFEE TO: PAYMENT <br /> San Joaquin County RECEIVED <br /> `nvironmental Health OCT 72003 <br /> Medical Waste Management Program <br /> 304 E Weber Ave PUg11°HEQALTH sEMACEs <br /> Stockton, CA 95202 ENVIRONMENTAL HEALTH DIVISION <br /> Medical Waste Hauler Information <br /> ® New 0 Renewal <br /> Medical Office/Business Name:. RehahFocus Home Health, Inc. <br /> Medical Office/Business Address: 1313 W. RohinhooH nr. , Suite A-4 <br /> City: Stockton State: CA Zip Code:95207 <br /> Contact Person: navies Raposa Phone T 472-7005 <br /> Storage Facility Name: SAA <br /> Storage Facility Address: <br /> City: State: Zip Code: <br /> Permitted Treatment Facility Name: � Ci ` W,lnC, <br /> Permitted Treatment Facility Address: <br /> City: - State: CA Zip Cade: 95368' <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> 1- Name: Cheri Newcomb, RN _ Title: nnr'.S <br /> 2- Name: Torrey Stadtner, RnT Title: Nursing Supervisor <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 to records shad be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: <br /> Title: Administrator Date: 1 0 / 03 / 03 <br /> Do Not Write Below This tine <br /> R.E.H.S. Application Approval: Date:/Q/7Z/Expiration Date:/7-/3//o <br /> EH4502 to-03.96 Date Paid 4a/ 2 IR-3C' heGIC y_4& (circle) Aca_. , <br />