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o c .v c SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT DEC 1 201 600 East Main Street, Stockton, CA 95202-3029 (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd ENVIRONMENT HEALTH PERMIT/SERVICES 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, transports 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 reaister pursuant to Chapter 4. Please complete the information below and mail with $77.00 fee to: I Ll E ' iI San Joaquin County Environmental Health Department Medical Waste Management Program 600 East Main Street, Stockton, CA 95202-3029 Medical Waste Hauler Information Lian Soling, M.D. George Herron, M.D. 11 New 11 Renewal 1610 N. Eldorado St. 1610 N. Eldorado St. Medical Office/Business Name: hx Suite 17 Suite 17 Medical Office/Business Address CA 95254 Stockton CA 95204 City State Zip Code Contact Person: Phone Number: v Storage Facility Name: �� L%�►, 6�b Qu ld�y,>,,��d Storage Facility Address: / , - City � qtateSvc@'7� Zip Code Permitted Treatment Facility Name: 1 Permitted Treatment Facility Address: _ Q; u" 4 22 Z City tate 'Zip C de List all employee names and titles authorized to transport the medical wasteIf more than 3, attach info): 1. Name: L �c�„ ,c.7.(�, ti' Title: 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: 0 Date: /2- �3�h Title: DO NOT WRITE BELOW THIS LINE REHS Application Approval: 1�'� �I• G Dates, C Expiration Date:L/H/ �L Date Paid: t117 I)/ 1� Cash or Check#: �D� I Received By: _ EHD 45-0111/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION