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SAN JOAQUIN COUNTY <br /> PAY1 <br /> OVIRON11 AL HEALTH DEP ENT C . <br /> b <br /> 60,D - Main Street, Stockton,CA 95202-3029 <br /> 5 2008 <br /> P/ Ted -3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR A LIMITED TITY HAULING EXEMPTION ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management Act",the following <br /> conditions must be met: <br /> ygnerator or health care professional generates less than 20 pounds of medical waste per week,transport less <br /> tliaii 20 pounds of medical waste at any one time,maintains a tracking document pursuant to Chapter 6 and the <br /> !tib= g rator or parent organization has on file one of the following: <br /> J. 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 /> 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: g ' <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 RRenewal <br /> Medical Office/Business Name: / - <br /> Medical Office/Business Address: <br /> C <br /> State Zip Code <br /> Contact Person: %� <br /> Phone Number: <br /> Storage Facility Name: <br /> Storage Facility Address: G <br /> City State Zlp Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: / 4- <br /> fire- <br /> Ut <br /> City ®� Stag— Zip Code <br /> J-ist all eployee names and titles 4uthorize-d to transport the medical waste(If more than 3,attach info) <br /> Name: Title: s� d <br /> 'L"' 2.2. Name: Title: <br /> G3.Name: Title: <br /> A co of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In <br /> addi dp,all copies of medical waste records shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: Date: <br /> Title: <br /> DO N T WRITE LOW THIS LINE <br /> R.E.H.S. Application Approval: Date: i/ 21/ <br /> -__--nom:�, <br /> Expiration Date: f l Date aid: t` / 7 / Cash o Check#:` Received By: <br /> EHD 45-01 <br />