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SAN JOAQUIN COUNTY o D ENVIRONMENTAL HEALTH DEPARTMENT ?. 600 East Main Street, Stockton, CA 95202-3029 DEC 21 2011 (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd ENVIRONMENT HEALTH APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION PERMIT/SERVICE 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: 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 pl_Irsuant to Chapter 4. Please complete the information below and mail with $77.00 fee to: . San Joaquin County Environmental Health Department Medical Waste Management Program 600 East Main Street, Stockton, CA 95202-3029 Medlcal Waste Hauler Informatlon ❑ New /iRenewal Medical Office/Business Name: C[C,—u �j (I' R-6- 0�[(�j Medical Office/Business Address c oeR-4-0d C CA 5-za 2 Cit State Zip Code Contact Person: h L( 002 16 Z Phone Number: I-oS,) 4 37- jV o/2- Storage Facility Name: C- t ry d/= STV ^/ Or-y:"T. 1441-S Storage Facility Address: 110 LJ, .So-.,ol" ST S70 CK7bn/, C,4 � 207 City State Zip Code Permitted Treatment Facility Name: S C yc L-E- If-lie . Permittod Treatment Facility Address: t 3 l./. Sc✓ r F-r O _ City State Zip Code List all employee names and titles authorized to transport the medical waste (If more than 3, attach info): 1. Name: _f FL-tPg�g lq-o o/L!G✓z5Z Title: F71k-lc C.4.10'*11%J 2. Name: /3 te /4-r✓ --rU %,-z:5!S Tit!e: F42,91- 3. Name: J/3-,C-E-yy/c Title: r-/A-,,- 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 medical waste records shall be kept on file at generator's or health care professional's facility. Applicant Signature- h Date: Title: DO NOT WRITE BELOW THIS LINE REN ((��S Application Approval: ��—s.1 t. W� ,��._ Date: Y 1 I� Expiration Date: V7V 1 / Date Paid: Z 111 Cash or Received By: EHD 45-0111/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION