Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
SAN JOAQUIN COUNTY <br /> OL, ENVIRONMENTAL HEALTH DEPARTMENT <br /> t -6232 <br /> 1868 East Hazelton Avenue, Stockton, CA 95206 <br /> (209)468-3420 Fax:(209)464-0138 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 bamet: - <br /> ! <br /> Thegmnaratof or health care professionalgenerates less than 20 pounds of medical waste per week, transports less ' <br /> than 2Opounds ofmedical wastea1anyonatine, nnainbansa tacking document pursuant tmChapter 8and the <br /> generator orparent organization has oil fi|ennaofthe 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 toregister pursuant tuChapter 4. / <br /> / <br /> 2' Information Document if the generator or parent organizabon is a small quantity generator not required to <br /> register pursuant to Chapter <br /> ED <br /> Please complete the information below and mail with $77.00 fee to: <br /> ~~^~~~,~'' ~~~''y~~'---ntal—H--- --'---- ^z^PP <br /> Medical Waste Management Program <br /> 1OG8East Hazelton Avenue, Stockton, CA 95205-6232 1 C-"T P) SAN T AL <br /> / <br /> HEA -Lf HmEP~~''- <br /> ENTM-edical Waste Hauler Information_ <br /> ONow IN Renewal <br /> Walgreens#10482 <br /> ` <br /> M*d��O�o�Bum��sKam� <br /> Medical Office/Business Address '"bvWest Lane <br /> Stockton CA 95210 <br /> cjty State Zip Coda <br /> Contact Person: Gulsinay Harris, On behalf of Walcireen. Co. <br /> Phone Number: (760)602-8700 <br /> Walgreens#10482 <br /> Storage Facility Name: '~~~``~~^~~'~ <br /> Storage Facility Address: ououxw// <br /> CA 95210 <br /> -. <br /> State Zip Code <br /> Permitted Treatment FamDitSharps Compliance, Inc. <br /> yName: <br /> Permitted Treatment Facility Address: ~~~~ '~'~x ~^'~~^' ~~'^~~~~ ' <br /> . <br /> city State Z1pCpop <br /> List all employee names and titles authorized to transport the medical waste(if more than 3,attach info): <br /> 1. Name: An p Nquven Title: Pharmacist <br /> 2. Name: Vivian Lee Title: Pharmacist <br /> 3. Name: Christine Chau Title: Pharmacist <br /> A copy of this exemption and a trackingdocument shall be in employeWs possession atall times while transporting medical waste. In addition,all copies v, <br /> medical waste records shall be kept on file at generator's or health Caro pro.fessionalls facility. <br /> ' AnoUbehalf Date: 12/05/2013 <br /> Title: <br /> D0 NOT WRITE BELOW THIS LINE <br /> | <br /> Expiration Date: 1 Date Paid: Cash rj�ec - 16-1 qReoelved By: 9-Q <br /> s*o*5-uu01z APPLICATION FOR*un <br /> � EoQummnvHAULING EXEMPTION <br /> | <br />