Laserfiche WebLink
98253283 Health Services 12:17:45 p.m. 02-05-2010 1 /2 <br /> ;.� :OG +JALV JVAIIUllr %_VUlvl Y <br /> a ENtiV9ONMENTAL HEALTH DEPARTMOT <br /> j 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: 209 468-3420 Fax: 209 468-3433 Web:www.s ov.or ehd <br /> \��C1F_��P • P � ) � ) Jg � <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 Ef Renewal <br /> Medical Office/Business Name: a U � Neck. S�tVit�� <br /> Medical Office/Business Address: 21'X 1 Wce,-- Lou ase_ Ave <br /> kNa n4as a CA4 CI C;3�'1 <br /> City State Zip Code <br /> Contact Person: Coxs-oVUa' xC 003o luau <br /> Phone Number: 20 q - ss S g- 0-19 <br /> Storage Facility Name: YY\CX n62c Q EISA-H�1+4-, Se-'ry icQS <br /> Storage Facility Address: Dank tnu iSeg-g <br /> M-a.n.AA-_S 13 Cd <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Skeri2 <br /> Permitted Treatment Facility Address: LAI" r Sly j�� C2s3o�C� <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: Co^okw\ Title: UC:ec:kpy nX- oiCen <br /> 2. Name: Vcuklmx O Jnlxa, Title:S thnpk rvu mr <br /> 3. Name: kcruP=,i' Title: StV c,DpN Y'\-vcue <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. PAYMENT <br /> Applicant Signature: s�o 11-W � Date: 0.111109 Ri-C-E,\V/CD <br /> Title: bk.,cec�M -c kAepLk& r <br /> DO N T I E BELOW THIS LINE SANJ0A')ulNCOUNTY <br /> WjIRONMENTAL <br /> R.E.H.S. Application Approval: Date: / pART MENT <br /> Expiration Date: /213/ / 16 Date Paid: / / D Cash or eck#:�` 3 9-J-Received By: <br /> EHD 45-011p�1 <br />