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N °o SAN JOAQUIN COUNTY <br /> . <br /> HEALTH DEARONMENTALPAR NT <br /> 600 East Main Street, Stockton, CA 95202-3029 `� <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/chd <br /> � y JAN 1 5 2009 <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPMNONMEN T HEALTH <br /> PERMIT/SERVICES <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the "Medical Waste Management Act",the following <br /> conditions must be met: <br /> The generator or health care professional generates less than 20 pounds of medical waste per week, transport 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 <br /> or a 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 <br /> to 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 <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Medical Waste Hauler Inform <br /> ❑ New 4Renewal <br /> Medical Office/Business Name: y►'1y( C � �/� �e t Q r�rnr <br /> Medical Office/Business Address: 40 U S N exrt Lyp <br /> Q City tt State Zip Code <br /> Contact Person: t.V '. at; ;� C� , r � '--Z,/ <br /> Phone Number: kKl b 2 <br /> Storage Facility Name: r✓t.0 P d e c� �- y: em- � <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: .e <br /> Permitted Treatment Facility Address: q/3 a— <br /> f(-e-S r�-d r- 9 3 7 a,�-- <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): <br /> 1. Name: C:t—t ��o� Title: <br /> 2. Name: Title: <br /> 3.Name: Title: <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical waste records shall <br /> /b/e keptt on file at generator's or health care professional's facility. <br /> Applicant Signature: ` w l'f � Date: )-- / 6 <br /> Title: _ i ,r a-k, 0- -e V..,1 <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: l ZZ /017 <br /> Expiration Date: 1�l 3/l Date Paid: Cash =Check I V 3/0 677 Received By: <br /> EHD 45-01 <br />