Laserfiche WebLink
r <br />O.P'qu I �• •.0 <br />SAN.JOAQUIN COUNTY <br />-' ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />(209) 468-3420 Fax.- (209) 464-0138 'Ain b• wwws ov / hd <br />PAYMENT <br />RECEIVED <br />FOR . ]g .org e <br />DEC - 6 2013 <br />APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTISN,IOAQUIN COUNTY <br />ENVlr�O"pAFITMENT <br />To qualify for a "Limited Quantity Hauling Exemption' pursuant to the "Medical Waste Management AIP Allowing <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 A pP�Q�]Ej <br />Medical Waste Management Program t� <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />❑ New <br />Medical Waste Hauler Information <br />N Renewal <br />Medical Office/Business Name: <br />Medical Office/Business Address <br />Contact Person: <br />Phone Number: <br />Storage Facility Name: <br />Storage Facility Address: <br />Permitted Treatment Facility Name: <br />Permitted Treatment Facility Address: <br />Dameron Hospital Association <br />525 W. Acacia St. <br />Stockton, CA 95203 <br />City State Zip Code <br />Mark G. Koenig <br />2094613184 <br />Dameron Hospital Association <br />525 W. Acacia St. Stockton, CA 95203 <br />City State zip Code <br />Dameron Hospital Association <br />525 W. Acacia St. <br />Stockton, C 95203 <br />City State Zip Cotte <br />List all employee names and titles authorized to transport the medical waste (if more than 3, attach info): <br />1. Name: —Per attached listing Title: <br />2. Name: - --- Title: <br />3. Name: Title: <br />A copy of this exemption and a trackino qpcument shall be in employee's possession at all times while transporting medical waste. In addition, all copies of <br />medical waste records shallator's or`health care professional's facility. <br />rM9" <br />Applicant Signature:- Date: 12/5/13 <br />Title: Mark G. Koenig, Director RMS <br />DO NOI%WRITE BELOW THIS LINE <br />REHS Application Approval: Date: 12.1 ID 1 t 3 <br />Expiration Date: 12, f-31 /14 Date Paid: /12-1 1 3 Cash or Check #:,*7_5! y Received By: - -- <br />EHD 45-01 512!12 APPLICATION FOR A LIMITFI) QUANTITY HAULING EXEMPTION <br />