BILLING - Laserfiche WebLink

Home Browse Search

Sah aquin County Public Health Servi Environmental Health Division Medical Waste Management Program APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical'haste Management Ate', the following :onditions must be met: The generator or health care professional generates less than 20 pounds of medical waste per week, tr nspors less `hon 20 pounds of medical waste at any one time, maintGins a �c'.<ing document pursuant to Chapter 6, and the generator or parent organization has an Me one of the fallowing: ;- Medica! Waste Management dart 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 it the generator or parent organization is a smait quantity generator not ,required to register pursuant to Chapter 4. PLEASE: COMPLETE THE INFORMATION BELOW AND MAIL WITH S67 F—==— TO: San Joaquin County Public Health Services Environmental Health Division Medical Waste Management Program 304 E Weber Ave Stockton, CA 95202 f" Medical Waste Hauler Information kE `vi New G Renewal r L N-k Li!f Medical ofnceiBusiness Name:L,Aw'RE e- LLE-Ni 1-.> 5 �,� Medical Ofi"celBusiness Address: ` }`F >✓7 State: C-A- Zp Cade:�).rj Ll C City: �t L o�7 i Phone CantactPnr50n: I :�-,l,f1t1 It_I< ),/ � D 'Jug I F Storage Facility Name: l� I�IL `�}` �_ y Storage Facility Address:,-3C,—j lora State: C•,� Lp Code: City- Permitted Treatment Facility Mame: Permitted Treatment Facility Address: I l VV State: C• rap Code: `), City: vlf�- S �riz> CL;,,X11, �— List all employee names and Wes authorized to transport the med's�l waste. If not enough space, attach information. 1- None: C 431'i Title:_i,1 N 1 wf��f-, 1� Title: N 01 2- i Name- l<R I`^ - r�.a f Title: r? 1+ 3- Name: n��7�> i ��54r,-) �IV�n F2�f7FrFY + =r of this exemption and a 4rackfn document be in employees possession at alj times while ttarfsporGng medical wa In A copy 9 addition, all copies of medical waste retards shall be kepi on file at generator's or health care professional's cf r Applicant Signature: Date: Title: 10 ti I Do s&Not Write Below This Lime Date: Il / ap station Date: Z I 1 ! j 4.E.H.S. Application Approval: �NaSoz t0-o3-45 Date Paid t 1221 Cash or Chec!< x Z 30—(circle)