Laserfiche WebLink
ui <br /> SAN JOAQUIN COUNTY ® PAYMENT <br /> ENVIRONMENTAL HEALTH DEPARTMENT �ECE <br /> 600 East Main Street, Stockton, CA 95202-3029 JUL - 72009 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> Sq N�RON�E OUIV7Y <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTI }1 oEPM k <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 /> VNew ❑ Renewal <br /> Medical Office/Business Name: 1- 7,S% /N& SiWI�LS, <br /> Medical Office/Business Address: ,Zit fQ � 17,6r A <br /> City State Zip Code <br /> Contact Person: /6 AJA <br /> Phone Number: <br /> Storage Facility Name: e <br /> Storage Facility Address: 1. A V6AU 17�A _ <br /> cam_ /2 CA-- s <br /> City MG.® .t C . State Zip Code <br /> Permitted Treatment Facility Name: QV/ 0, , /'5&J, spt4!`1•__,11 <br /> Permitted Treatment Facility Address: <br /> —SW _-` Lo ZE .� — ©r-Ficc= <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): <br /> 1.Name: Gikd Title:;�1*�� �i� 6! g j'/� <br /> 2.Name: c7 / Title: - c/)/Ile,c. <br /> 3.Name: a— 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 shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: l ' Date: <br /> Title: tadLxl <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: /15_/-1:1 <br /> Expiration Date: - (2/g j Date Paid: / / Cash or Check#: S S Received By: (�s <br /> EHD 45-01 <br /> 11/19/08 <br />