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a Pqu�N SAN JOAQUIN COUNTY r PENT z ' ENVIRONMENTAL HEALTH DEPARTMENT i JARECEIVEDN Z N :I 1868 East Hazelton Avenue, Stockton,CA 95205-6232 201 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd �R NM cou F4L77q DEp��AI APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION °Vr 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 ire ROV APPROVED FOR PAYMENT San Joaquin County Environmental Health Department �. a JAN 14 20% Medical Waste Management Program 1868 E. Hazelton Avenue, Stockton, CA 95205-6232 - Medical Waste Hauler Information ❑ New $1 Renewal Medical Office/Business Name: kin I Pan^'�`� Cewjt' Pta 14% W n'L Medical Office/Business Address: (o y t) L-A-fc4 V e+-Fe S�oGl�to n cA 162o-5 City State Zip Code Contact Person: A IS5G AYi'5Vy)f(I d� --AI%)a 1"-e z- Phone Number: (aa q) 3-7.3- 2 9 8 9 Storage Facility Name: '�i`n Fein IV C-e-,Y1+C K P-ea Wn Cl;;n i G Storage Facility Address: "2b Ifo 6 • I-a-f'G d644-e -44 -e-e+ 5j:vCY-4-&vt I CA '9-5720-5 City State Zip Code Permitted Treatment Facility Name: 13�ric-yC�,' Permitted Treatment Facility Address: I f 8'7S wh-,•-fe F-Iocle- Rd. Rayictio Cord orrG i eA ci 5-7'-z City State Zip Code List all employee names and titles authorized to transport the medical waste(If more than 3,attach info): 1.Name: LO(lA MarX Title: 4Zee-1 i si-crcd N u-ae, 2.Name: A l bxr+-o Sar-dwa l Title: P—ie, gyred Mar5e 3.Name: M i r)erva (aa ra'& Title: U i n;L Ma kicQ-C� A copy of this exemption and a tracking docu t shall be in employee's possession at all times while transporting medical waste. In addition,all copies of medic as a records al a ept of at generator's or health care professional's facility. Applicant Signature: Date: 1 1 1�1 Title: C/ DO NOT WRITE BELOW THIS LINE R.E.H.S. Application Approval: Date: Expiration Date: Z/ 31 Date Paid: f l Z� l Cash o Chec Received By: EHD 45-01 11/19/08