Laserfiche WebLink
EASAN JOAQUIN COUNTY 740 <br /> oNMENTAL HEALTH DEP .*,F f L E XT <br /> 600 East Main Street,Stockton,CA 95202-3029 -.JVr_1) <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/chd ��'� 200$ <br /> F 8AN`0AQU1N COUN7V <br /> APPLICATION FOR A LIMITED QUANTITY.HAULING EXE�Iy �IMN1+ <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 /> l 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 q r u' <br /> to register pursuant to Chapter 4_ <br /> Please complete the information below ante!Mall with$72.00 fee to: <br /> San,Joaquin County Environmental Health Department JAN 3 0 2008 <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton,CA 95202-3029 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> tZ C 1 S R t e $ U CJ&f o t l t) HEALTH DEPARTMENT <br /> 0 New j Renewal <br /> Medical Office/Business Name: �(i� ti ��-�ll�►�� <br /> Medical Office/Business Address: 2' '.C/ <br /> r�. 05 <br /> City State Zip Code <br /> Contact Person: —vlb � <br /> Phone Number: <br /> Stordge FaciIity'Addtesg:: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: 4&v "(JG <br /> Permitted Treatment Facility Address: <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste(W more than 3,attach info) <br /> 1. Name:cry '. 2 Pn Title: �l <br /> 2. Natzme, - ro"CG _.14#r'�'5 I Title: LAN-1. <br /> 3. Name: __ (;iirun b—h- _'l�� Title: <br /> A copy of this exemption and a tracking docament shall be in employee's possession at all times while transporting medic4l waste, In <br /> addition,all copses of medical waste records shall be kept on file at generator's or health care professional's facility, <br /> L <br /> Applicant Signature: __ l.�L - � �.� Date. <br /> Title: WYU ! , <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H,S, .Applicatyon,A,pprov , Date: <br /> Expiration Date: _� �' #_ 5 Llo Received By ,�,� <br /> EI{D 45.01 v <br /> 10/02/07 <br />