Laserfiche WebLink
i <br /> EN-viRoNmENTAL HEALTH DEPARTMENT �rr CE <br /> Jdf 600 East Main Street,Stockton,CA 95202-3029 '= <br /> Telephone:(209)465-3420 Fax.(209)465-3433 Web:w-,vw.sjgov.org/ehd MAR 0 2010 <br /> APPLICATION FOR A LIMITED U TI Y HAULING E 1 1QN,[VUj H!"al'TIj <br /> MIT/SERVICETo qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management Act",the follow g <br /> cond.t:e»s must 1�-, =*, <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 /> aaenQratcrr or parent orga�lt ±on has-on file,one,of the fallowing: <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. In,formation Document-if-the generator or parent organization is a shall quantity generator not required <br /> to register pursuant to Chapter 4. <br /> Please complete the information below and mail with$77.00 fee to: <br /> San Joaquin County Environmental-Health Department <br /> Medical Waste Management Program <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Medical Waste Hauler Information <br /> New ❑Renewal <br /> Medical ffice usie>ess Name, MiVe ITV OF ,f' , <br /> Medical Office/Business Address: -3&01 <br /> City State Zip Code <br /> Contact Person: , iza �-,- iZe-Phone Number: �.. 'l =7Ct� � L01 <br /> Storage Facility Name: u - " .,i 0 - or to <br /> Storage Facility Address: 751 36a' ` 97th. <br /> C--A= 7 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: ``f C2, <br /> Permitted Treatment Facility Address: L$l lj t-F--T <br /> A <br /> tE- ,Ko, CC1 "1�Z <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: i�— t`<!L'4 ' Title: <br /> 2.Name: L 1 Title: -.jf,1 " <br /> 3.Name: �/b'l is4 Title: <br /> -T- <br /> A <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 os' ste r cords shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: - ' f���� Date: I <br /> Title: P1'* <br /> D® NOT WRITE BELOW THIS LINE <br /> R.E.FI.S.Application Approval: Date: A&/&I-L-0 <br /> Expiration Bate:11, / 31 /10 Date Paid: Cashr Checl� 13Y L Received By:T � <br /> EHD 45-01 a ZD <br /> 11/19/08 <br /> / �1 <br />