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� <br /> SAN JOAQUlN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> WL <br /> V. 18G8East Hazelton Avenue, Stockton, CAS52O5-0232 <br /> (2OQ)488-842UFax: (2OQ)4O4'0138Web: vvwom. gov.org/ehd <br /> APPLICATION FOR 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 bemet: <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 orparent organization has unfile one nfthe following: <br /> 1. Medice/N/aabeMenagennentPlanifthaganerabororponuntorganizationioa |orgaquentitygenaradororo <br /> small quantity generator required toregister pursuant toChapter 4. <br /> 2. Information Document if the generator or parent organization is a small quantity generator not required to <br /> register pursuant boChapter 4. <br /> Please complete the information below and mail with $77'00 fee to: <br /> San Joaquin County Environmental Health Department APPROVIED <br /> Medical Waste Management Program <br /> 1888East Hazelton Avenue, Stockton, CAQ52O5-G232 <br /> Medical Waste Hauler Information <br /> � <br /> ONow l�~nenovva| <br /> Medical Office/Business Name: <br /> Medical Office/Business Address <br /> Contact Person: <br /> Phone Number: 62P <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> city State Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: <br /> List all employee names and titles authoriZed to tra po the edi \vvaote (If more than 3 attach info): <br /> 1. Name: Ar Title: <br /> 2. Name: Title: <br /> 3. Name: Title: <br /> A copy of this exemption and a tracking clocument shall be in emp e,possession at all times while transporting medical waste. maddition,all copies m <br /> medical <br /> ��^ ~ Date:Applicant S.'anature: <br /> � <br /> DO NOT WRITE BELOW THlS LINE <br /> REH8Ap Date- <br /> 0--Expiration Date: Date Paid: /~~ 17 1 IX.caono nexowuu ov'��z�_____ <br /> sxo^so1mo1c APPLICATION FOR ALIMITED QUANTITY HAULING EXEMPTION <br /> �� <br />