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SAN JOAQUIN COUNTY E NMENTAL HEALTH DEPART 304 East Weber Avenue, 3d Floor, Stockton,CA 95202-2708 P (209)468-3420.Fax:(209)468-3433 • Web:www.co.sanjoaqum.ca.us/ehd R<<FOR a` 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. 'Yid-;i=�°�..� Please complete the information below and mail with$70.00 fee to: RE0EIVI=D San Joaquin-County Environmental Health Department Medical Waste Management Program DEC 15noun 304 East Weber Avenue, 3'd Floor, Stockton,CA 95202 SAN JOAQUIN COUNTY ENVIRONMENTAL Medical Waste Hauler Informations LTH DEPARTMENT ❑New Renewal Medical OfficeBusiness Name: Medical Office/Business Address: 9 1 =02bo` P/ 7 �- City State Zip Code e Contact Person: : - '' Phone Number: ,' 0;l Storage Facility Name: I^ 1,,ahJ , c�u�t�' �-�� C �� &O Storage Facility Address: S7 6 6/o il" E/ )ok A T 7 City State Zip dode Permitted Treatment Facility Name: Pk-44 XJd. Gti )6_z P H 6'7 t" o to Permitted Treatment Facility Address: A 6, � kAbA 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: /�1 2.Name: � — Title: 3. Name: Title: 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 waste records shall be kept on file at generator's or health care professional's facility. Applicant Signature: Date: la/ 4 Title: DO NOT WRITE BELOW THIS LINE R.E.H.S. Application Approval: Date: Expiration Date: / / Date Paid: / / / / 0 6 Cash Check . h Received By: EHD 35-02-001 10/7/2003