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-06-2006 11:20am From- 209-476-3869 T-650 P.002/002 F-011 <br />-� ENMONMENTAL <br />--- - - DEPARTMENT <br />304 East Weber Avenue, 3'e floor, Stockton, CA 95202-7-708 <br />(209) 448-3420 • Fax: (209) 468-3433 • Web. wWw.c®.san joaqum.ca.uatehd , <br />APPLICATION FOR A LBUTED QUANTITY HAULING MMPTION <br />To qualify for a "Limited Quantity Hauling Exemption» pursuant to the "Medical Waste Management Ac', the following, <br />conditions must be met: <br />The generator or Health care professional generates I 20 polmds of medical waste per week, transport less <br />than 20 pounds of medical waste at any one time, maintains a tmcking document pursuant to Chapter 6 and <br />the <br />generator or parent organization has on file one of the f0llOwing-. <br />1. Medical Waste Management Plan if ft generAtor or parent organization is a laW quantity generator <br />or a small quantity generator required to register pursuant to Chapter 4- <br />2. Information Document if the generator t iz°ation is a small quantity tar not required <br />to register pursuant to Chapter 4. <br />Please complete the information below and mail with $70.00 fee to: <br />"San Joaquin -County -Environmental health Deparl==t <br />Medical Waste Management Program <br />304 East Weber Avenue, 3'4 Moor, Stockton, CA 95202 <br />Medical Waste H§ ler Informatioli <br />[3 New Renewal <br />Medical OfiicVBusiness dame: <br />Medical OfficeJBusiness Address: <br />Storage Facility Name; <br />Storage Facility Address: <br />Permitted Treatment Facility Mame: <br />Permitted "Treatment• Facility Address: <br />City State Zip Code <br />-esno <br />City State Zip Code <br />Last all employee names and titles authorized to ftlasPuTt the medical waste (If mom than 3, attach info): <br />1 _ Nie. Tine: A; <br />,k-- <br />2, Name: Title: 24 <br />3. Name: <br />v tdrsa <br />A copy of this exemption and a tracking document shall be is etaplayee's ss ton At All times while trawportin= mt0cal waste. to <br />addition, all copied of medical waste rpeords shall be kept an fol at generator's or health Fare professional's bellity. <br />Applicant Signature: <br />Title: <br />DO NOT WRITE BELOW <br />nate: <br />Application <br />Expiration Dau: / / Date Paid: /Cash or Check Received BY- <br />up <br />45-02-M <br />