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SAN JOAQUIN COUNTY z ENVIR*MENTAL HEALTH DEPARTME4 600 East Main Street, Stockton, CA 95202-3029 • cc, `P Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd A�7FOR APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION 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, transport 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 pursuant to Chapter 4. Please complete the information below and mail with$72.00 fee to: San Joaquin County Environmental Health Department PAYMENT Medical Waste Management Program 600 East Main Street, Stockton, CA 95202-3029 R FCE I V F n C 6 2007 Medical Waste Hauler Information SAN JOAQUIN COUNTY Q New enewal ENVIRONMENTAL / ,, HEALTH DEPARTMENT Medical Office/Business Name: 6�e- //)7 4- /�-,�evlleme V Medical Office/Business Address: City - State Zip Code Contact Person: �.� )lz)rjeey, c5 0� / Phone Number: 2 Storage Facility Name: —k ' Storage Facility Address: 4EX44224 4: City Staiel Zip Co e Permitted Treatment Facility Name: Permitted Treatment Facility Address: C' L - City State Zip Code List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): 1. Name: Title: 2. Name: Title: 3. Name: Title: i 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 wast records shall be onn fi^le at g erator's or health care professional's facility. ' V f Applicant Sw'gnature: `� Date: Title: DO NOT WRITE BELOW THIS LINE R.E.H.S. Application Approval: Date: Expiration Date: / / Date Paid: 12-l OG / D 7 Cash or Check#: Received By: EHD 45-01 10/02/07.