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u�N' AN JOAQUIN COUNTY <br /> G�< ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue, 3Yd Floor, Stockton,CA 95202-2708 <br /> (209)468-3420.Fax:.(209)468-3433 • Web:www.co.san-joaquin.ca.us/ehd <br /> {11:0 <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;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$70.00 fee to: <br /> San Joaquin-County Environmental Health Department <br /> Medical Waste Management Program <br /> 304 East Weber.Avenue,3Td Floor, Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> ❑New ❑ Renewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: <br /> City State Zip Code <br /> Contact Person: <br /> Phone Number: <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: <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: <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: Date: <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S.Application Approval: Date: <br /> Expiration Date: / / Date Paid: / / Cash or Check#: Received By: <br /> EHD 45-02-001 <br /> 10/7/2003 <br />