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' ° .... c� SAN JOAQUIN COUNTY <br /> ENOONMENTAL HEALTH DEPARTIOT <br /> IN600 East Main Street, Stockton, CA 95202-3029 T <br /> �\r j Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd <br /> R r�oRi'� <(. <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIOf'o/oqQ 1 0 2009 <br /> H�TVtg9/V IN o0U <br /> To qualify for a "Limited Quantity Hauling Exemption"pursuant to the "Medical Waste Management Act" ,fin <br /> N � N� <br /> conditions must be met: FNT <br /> The generator or health care professional generates less than 20 pounds of medical waste per week,transport 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 <br /> or a 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 <br /> to 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 <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: �e� �• <br /> City State Zip Code <br /> Contact Person: !-r��� <br /> Phone Number: 6 q�9�z� —gyp, �Ad,�,? egyj <br /> Storage Facility Name: _ <br /> Storage Facility Address: <br /> �d <br /> City State Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: ( W <br /> X596 City tate Zip Code <br /> List all employee names and titles authorized to trans ort the medical waste (If more than 3, attach infoj':� <br /> 1. Name: Title: <br /> 2. Name: Title: <br /> 3. Name: Title: <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical waste records shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature. i'� �� Date: <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: -�►t ej.�q�,,�_ Date: -L/31 /01 <br /> Expiration Date: -AL, / / lb Date Paid: \ 2— /-0A Cash or heck#• Received By: �Cf <br /> EHD 45-01 <br />