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PAY Nr <br /> 4 N. <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> '• 1868 East Hazelton Avenue, Stockton,CA 95205-6232 DEC I 'QUW� <br /> (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd gyinrry <br /> �FOR TM� <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <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 <br /> �to: <br /> [7 <br /> v r <br /> San Joaquin County Environmental Health Department APP E <br /> Medical Waste Management Program <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Medical Waste Hauler Information <br /> 0 New 0 Renewal <br /> Medical Office/Business Name: City of Stockton Fire Department <br /> Medical Office/Business Address 425 N El Dorado Street <br /> Stockton CA <br /> City State Zip Code <br /> Contact Person: Jeff Smeenk <br /> Phone Number: (209)937-8012 <br /> Storage Facility Name: City of Stockton Fire Department.ENIS <br /> Storage Facility Address: 110 W.Sonora Street.Stockton CA 93_ <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Stericycle Inc <br /> Permitted Treatment Facility Address: 4135 4v. %%ift Road <br /> Fresno CA 93 121_ <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: JeBSmeenk Title: Fire Captain <br /> 2. Name: Brian Jones Title: Fire Captain <br /> 3. Name: Brandon Doclan Title: Fire Captain <br /> A copy of this exemption and a tracId' ocu nt shall be In a ployee's possession at all times while transporting medical waste. In addition,all copies of <br /> medical waste records shall be ks lea eneratot's or fWalth care professional's facility. <br /> Applicant Signature: Date: 12-2-2013 <br /> Title:Captain EMS <br /> DO NOT WRITE <br /> BELOW THIS LINE <br /> REHS Application Approval: Date: LL/A ' ! i�'� <br /> Expiration Date: \-I--/721 Date Paid: /-3 Cash or 49#: /� Z`� Received By: <br /> EHD 45-015,0112 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />