Laserfiche WebLink
4 . SAN JOAQUIN k—OUNTY <br /> j ENVIRONMENTAL HEALTH DEPARTMENT FILE CDK <br /> s�•� 600 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: ;5f1_n wtCz <br /> Medical Office/Business Address: 7 1 Ca <br /> 54-Do,k-fm-� C,a 61s DD(, <br /> Clh' State Zip Code <br /> Contact Person: S h-c l <br /> Phone Number: <br /> Storage Facility Name: Cts-) ,j OL�stI-) ,W L, Of–A ps, DE (-d tt utKn1 <br /> Storage Facility Address: 3�1�� 1�o 1151Jl;Grld I i' <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Eel <br /> Permitted Treatment Facility Address: 1521 q NE Loop <br /> 0-a-s-�1)aA-P- i x _76.(-` j <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:�NYl1 l� 7 P I' I YIOt d 1, (�i Title: _� k-, r;r- <br /> d f 11L>lZ�l' <br /> 2. Name: Title: <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 mAwasteords�shall�be kept on file at generator's or health care professional's facility. <br /> Applicant SignaturU4^ Date:Title: i r� �� v I�1 , rC> — <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: <br /> Expiration Date: / / Date Paid: / / Cash or Check#: Received By: <br /> EHD 45-01 <br />