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SAN JOAQUIN COUNTY _ ? EN*ONMENTAL HEALTH DEPART y {� L EPyyAdENT 600 East Main Street, Stockton, CA 95202-3029 CEIYED Telephone:(209)468-3420 Fax: (209)468-3433 Web: www.sjgov.org/ehd JAN �crFaR?� 2011 ` � Q APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION '4 F"J�A,0),U,rN,10,u, HF��rH CEPA TMgL �P To qualify for a"Limited Quantity Hauling Exemption"pursuant to the "Medical Waste Management Act", the following conditions must be met: The generator or health care professional generates less than 20 pounds of medical waste per week, transport less than 20 pounds of medical waste at any one time, maintains a tracking document pursuant to Chapter 6 and the generator or parent organization has on file one of the following: 1. Medical Waste Management Plan 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 if the generator or parent organization is a small quantity generator not required to register pursuant to Chapter 4. Please complete the information below and mail with $77.00 fee to: San Joaquin County Environmental Health Department Medical Waste Management Program 600 East Main Street, Stockton, CA 95202-3029 Medical Waste Hauler Information ❑ New Renewal Medical Office/Business Name: Ve.(m a-nrw� (y\A.(4e-c& to U-`=-\k-a-' Medical Office/Business Address: -l�l \) . q o OWt-}e c a Cit(-, cis 3377 CityState Zip Code Contact Person: I;r-04+ rDD:aSS1 Phone Number: aim — 1259- 762) p Storage Facility Name: i Stw 'PefW\O n e.,yiti Storage Facility Address: Q. LApseenz "44ceN CIA S33-7 City State Zip Code Permitted Treatment Facility Name: Permitted Treatment Facility Address: 41 w;- City State Zip Code List all employee names and titles authorized to transport the medical waste (If more than 3, attach info): 1. Name:��C.p��o"rri S Title: Q�(- 2._Name:Imam alun__ Title: _ . 3. Name: Title: 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 medical wasteFtprds shall be kept on file atgenerator's or health care professional's facility. Applicant Signature; Date: 1'7,f-7/-1�l Title: ' DO NOT WRITE BELOW THIS LINE R.E.H.S. Application Approval: ^ Date:0j—/0 Expiration Date: �2/�/ Date Paid: �/ 3 / _ Check • d Q-Received By: (� EHD 45-01