COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY � 1\ 1 z G ENVIRONMENTAL HEALTH DEPARTMENT • 1868 East Hazelton Avenue, Stockton, CA 95205-6232 �q•-1N�P (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd LrFOR APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION To qualify for a"Limited Quantity Hauling Exemption" pursuant to the"Medical Waste Management Act", the following conditions must be met: The generator or health care professional generates less than 20 pounds of medical waste per week,transports less than 20 pounds of medical waste at any one time, maintains a tracking document pursuant to Chapter 6 and the generator or parent organization has on file one of.the following: 1. ' Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a small quantity generator required to register pursuant to Chapter 4. 2- Information Document if the generator or parent organization is a small quantity generator not required to register pursuant to Chapter 4. Please complete the information below and mail with $77.00 fee to:San Joaquin County Environmental Health Department ��RqVMedical Waste Management Program 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Medical Waste Hauler Information ❑ New ❑ Renewal Medical Office/Business Name: SCS Joaq QEM T�� 33�+Cy, &f �Ga UCa-fi m Medical Office/Business Address Z-1b-1 ��^ncc,,r,✓\�i n.,;.rt� S�oc��I�nI CA 25-uj�o City State Zip Code Contact Person: 4,3y g n Cr-bur fl- D -eC Tri -ns�ve ilea-u=gh 12 f0- Phone Number: _2-0c(-lAkR-M9 (-) Storage Facility Name: Jar",)C)OckIILn cKh (4 EC ShJOu� Storage Facility Address: 71C;-i 711(-1 y City State CA Zip Code Permitted Treatment Facility Name: Permitted Treatment Facility Address: City State Zip Code List all employee names and titles authorized to transport the medical waste (If more than 3, attach info): 1. Name: S\ne r ,CA-)Vk -n 'x-11 Title: 1D\-C. Cluv—v5NJe., kk-ef�� ?""yarns 2. Name: 94,,6k r� OW . V�N Title: Cob,(AwNn.-t-or -'IC F�C ,00\\Lk 3. Name: C c)yv,- Es--Gs eV- Title: -JZ l_ R xt�� A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. in addition,all copies of medical waste records shall be kep file at generatof s or health care professional's facility. Applicant Signature: Date: t l DC7 1'L Title: DO NOT WRITE BELOW THIS LINE REHS Application Approval: ( � --s Date: k21I-tylil.- Expiration Date: %1,�/ Date Paid: S/ /�-Cash or eck Received By: EHD 45-01 5012 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION l