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(�U t ty <br /> SAN JOAQUIN COUNTY <br /> 'y EN WONMENTAL HEALTH DEPART&TF1 Y <br /> 600 East Main Street, Stockton, CA 95202-3029 �Ifc AD <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web: www.sjgov.org/ehd DEC4 2008 <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPf1"Vj1AauiN COUNTY <br /> HEALTH�� ENTAL <br /> To qualify for a "Limited Quantity Hauling Exemption"pursuant to the "Medical Waste Management Act , &VVWwing <br /> conditions must be met: <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: Joe,_n C, <br /> Medical Office/Business Address: �:zT_.4,7 <br /> City State Zip ode <br /> Contact Person: cc ', <br /> Phone Number: 0 Y - <br /> Storage Facility Name: oetics, <br /> Storage Facility Address: j6q UE , /{ /] 5-A <br /> toLtt 117 q /C} <br /> City State Zip Code <br /> Permitted Treatment Facility Name: '%,r; c tc <br /> Permitted Treatment Facility Address: _ 136 W- SW Acme ci-wWo-S. 4_ <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: Title: "CP 44,1 A A.11J A <br /> 2. Name: /hz9v, Title: ,�A,.e <br /> 3. Name: '4k. .1 A- Title: <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times wh' a tr nsporting medical waste. In <br /> addition,all copies of medical waste ecor s Il rept le at generator's or health care professional's facility. <br /> Applicant Signature: Date: 09 <br /> Title: /`est d¢a.t <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: � Date: A //I/10'et <br /> Expiration Date: Date Paid: /,2-/ V 4/ 0�& Cash or heck : 1-7 1-7 Received By: <br /> EHD 45-01 <br />