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� 1 <br /> r r RE-GENED <br /> 201 SAN JOAQUIN COUNTY p�Y �NT <br /> {�R ENVIRONMENTAL HEALTH DEPARTMENT R�C�JVFD <br /> RONMENTALHE4MB68 East Hazelton Avenue,Stockton, CA 95205-6232 MR 4 <br /> ° til iac���P PERMITI8ENCEt09)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd J04Q(rgy <br /> ZQ'l� <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION � �P� Q <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, transports 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 or a <br /> 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 to <br /> 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 -ATP ON <br /> Medical Waste Management Program <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Medical Waste Hauler Informatlon <br /> ❑ New Renewal Addus litfth care <br /> Medical Office/Business Name: 8°1 7 Croffe,e R a°" <br /> Medical Office/Business Address s r �t <br /> .1-11, D �l`1i. fEf��` t,ul <br /> � �et�tfa <br /> City State Zip Code <br /> Contact Person: cL CA n-W <br /> Phone Number: r <br /> Storage Facility Name: � 1� iew�� <br /> Storage Facility Address: _ g <br /> City/,\% 81 ' c o f �rtle Rd.- <br /> - d� Zip Code <br /> Permitted Treatment Facility Name: f fIC R�+€; 96355 <br /> Permitted Treatment Facility Address: < <br /> City State Zip o(re <br /> List all employee rl=es and titles uthorized to transport the medical wa (If ore than 3,attach info): <br /> 1. Name: G Title: <br /> 2. Name: l r Title: <br /> 3. Name: Y C` SIC' Title: <br /> A copy of this exemption and a tracking document shall be In employee's possession at all times white transporting medical waste. In addition,all copies of <br /> medical waste records shall be kept <br /> on f-ille—att generator's or health care professional's facility. <br /> Applicant Si natu �J .ice- -•-- a Q---� Date: 4\r_��aQ�\A� <br /> Title: � ' c..Ap— YY'N ar-.c.�� 2 <br /> DO NOT <br /> WRITE BELOW THIS LINE <br /> REHS Application Approval: Date: <br /> Expiration Bate:�J�J Date Paid: 3 J �o J� Ch <br /> Cash ep : 531 Received By:.� <br /> EHD 45-01 5WJ2 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />