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u►r� SAN JOAQUINCOUNTY ° d <br /> ..... ,_.,?� ENVIRONMENTAL HEALTH DEPARTMENT <br /> { 600 East Main Street, Stockton, CA 95202-3029 F: 2012 <br /> (209)468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br /> ENVIRONMENT ti BELT <br /> APPLICATION F LIMITED QUANTITY HAULING EXE PTI® ERIT/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, 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 <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ❑ New Renewal Addus Healthcare <br /> Medical Office/Business Name: 7 Coffee Rd ® Rhio, P1 <br /> Medical Office/Business Address <br /> City State Zip Code <br /> Contact Person: <br /> Phone Number: <br /> Storage Facility Name: duS Healthcare <br /> Storage Facility Address: <br /> City t "lipCode <br /> est®, CA 95355 <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: <br /> City State Zip Code <br /> List all employee s and titles au horized o transport the medical wa (If ore than 3;attach info)- <br /> 1. Name. _ Title: <br /> 2. Name: Title: <br /> 3. Name: Title: Le <br /> 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 <br /> medical waste records Wial.Lbe kept on file at generator's or h h care professional's facility. <br /> Applicant n t e: c, Dat : <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: Date: o / <br /> Expiration Date: ��/? 1 / Date Paid: /�1 / Cash or Check# Received By: <br /> EHD 45-0111/29111 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION <br />