Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> f EIMONMENTAL HEALTH DEPARTOT FILE COPY600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <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 $77.00 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 /> ❑ New Renewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: lil4o bTAfw <br /> City State Zip Code <br /> Contact Person: Umft I W, bpr <br /> Phone Number: p . <br /> Storage Facility Name: <br /> Storage Facility Address: 1� <br /> City State Zip Code <br /> Permitted Treatment Facility Name: _MA CAV <br /> Permitted Treatment Facility Address: u <br /> Qilr o 00 <br /> City IState 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: m& <br /> 2. Name: .ALAW V44W Title: _ WIN/(�I <br /> 3. Name: AL" �ilFofvblu Title: kk <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. <br /> Applicant Signtures f/�-dtr✓ 1)1 Date: <br /> Title: �,Q IhX�✓ <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: _ � � ,(� Date: / /Zr/ (5q <br /> Expiration Date: _j Z� ✓t /_ Date Paid: 1)—/ I O / 01 Cash o heck#._IP a Received By: — <br /> EHD 45-01 <br />