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RaLlii� SAN JOAQUIN COUNTY necetv ENVIRONMENTAL HEALTH DEPARTMENT . E.D 1868 East Hazelton Avenue, Stockton, CA 95205-6232 JAN (209)468-3420 Fax: (209)464-0138 Web:www,sjgov.org/ehd ® 20j ciT;o APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIONS pIERNMENTL MIT/SER IV CES � 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, transports 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: i 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 1kpr Medical Waste Management Program 1868 East Hazelton Avenue, Stockton, CA 95205-6232x Medical Waste Hauler Information 0 New Renewal Medical Office/Business Name: -T Medical Office/Business Address �7 _N• 6, k to-A-DO S; S7'.ctZ&i CA-- a SZ�C•3 City State Zip Code Contact Person: CAPt-ifs! Sok- Phone Number: ZC21 W-7 `r irolj SStorage Facility Name: c2� - Storage Facility Address: 110 W, vo City State Zip Code Permitted Treatment Facility Name: INr Permitted Treatment Facility Address: 141A91TT wn4d� Fero c.4_ 93-qZ2 City State Zip Code List all employee names and t' es authorized to transport the medical waste(If more than 3, attach info): 1. Name: Title: Cit f� 2. Name: 21 ON Title: 0417- ol;-/1v 3. Name: Title: CV f bgr A copy of this exemption and a tracking do ment shall be in employee's possession at all times while transporting medical waste. in addition,all copies of medical waste records shall be kept o fil t generator's r healthcare professional's facility, Applicant Signature: hate: t11,7-! 7-0,1`:— Title: it/ 06Wtt" — < n DO NOT WRITE BELOW THIS LINE REHS Application Approval-0 / Q!-?��----� Date: 61 /01/ /.3 Expiration Date:�1�/�Date Paid: / /7/ JJ Cash or Chec x/27 IX3 Received By: EHD 45.01512112 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION