Laserfiche WebLink
SAN JOAQUIN COUNTY I& p <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> { 600 East Main Street, Stockton, CA 95202-3029 <br /> DEC 232011 <br /> (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd ENVIRONMENT HEALTH <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION PERMIT/SERVICES <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, transports 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 or a <br /> 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 to <br /> 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 ORenewal <br /> Medical Office/Business Name: Vs <br /> Medical Office/Business Address Zr <br /> City -F�I I C.-ye <br /> Zip Code <br /> Contact Person: <br /> Phone Number: 2 1 (0- 77 U7 <br /> Storage Facility Name: Sa y" <br /> Storage Facility Address: <br /> City <' State Zip Code <br /> Permitted Treatment Facility Name: k-s( at <br /> Permitted Treatment Facility Address: 1 -G __ <br /> r-A--- <br /> City State Zip Code <br /> List all employee nam (If and titles authorized to transport the medical wastbe than ): <br /> 1. Name: hM 14 G,61 IGS Title: 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 addition,all copies of <br /> medical waste records shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signat e: ` a" Date: <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: UU, Date: tel <br /> Expiration Date: ��' / 31 / Date Paid: 1Z /Z3/ I i Cash orCheck# 640 Received By: <br /> EHD 45-0111/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION <br />