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E 't <br /> C <br /> RAU <br /> SAN .10AQUIN COUNTY 10 D <br /> ENVIRONMENTAL HEALTH DEPARTMENT DEC 21 2011 <br /> ?. 600 East Main Street, Stockton, CA 95202-3029 <br /> ENVIRONMENT HEALTH <br /> (209) 468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd PERMIT/SERVICES <br /> cqC�oR �P <br /> APPLICATION FOR A 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 be met: <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 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 or a <br /> 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 to <br /> 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 N?I enewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address <br /> S <br /> City State Zip Code <br /> Contact Person: <br /> Phone Number: <br /> Storage Facility Name: <br /> Storage Facility Address: u �Z-. C- <br /> City S State (3\S�Lo-j Zip Code <br /> Permitted Treatment Facility Name: �Nlt� <br /> Permitted Treatment Facility Address: �A,--.,_ �P -_- <br /> cx c O CA . <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste (If more than 3, attach info): <br /> 1. Name: U -O Title: <br /> 2. Name: Title: <br /> 3. Name: C_� C�k CK 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 addition,all copies of <br /> medical waste records shall be kept on file at generator's or health care professional's facility. <br /> ApplicqQt.Signat re: da . GILb �, Q Date: - " 1 <br /> Title: \)Ck\-\� GV, <br /> �eceS <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: V��: tDate: %±1=_1k <br /> Expiration Date: lZ/ 3� /i2 Date Paid: t?// ZI/ Cash oCheck# �1 Received By: �/U <br /> EHD 45-0111/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION <br />