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�q rCOUNTY _ <br /> JAN 3 2012 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> l 600 East Main Street, Stockton,CA 95202-3029 <br /> ENVIRONMENT HEALTH <br /> ` Telephone:(209)468-3420 Fax;(209)468-3453 Web.www.s}gov.orgland PERMIT/SERVICES <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 fila 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 577.00 fele to: <br /> San Joaquin County Enviromnental Health Department <br /> Medical Waste Management Program <br /> 600 East Main.Street;Stockton;CA 93202-3029 <br /> Medical Waste Hauler Information <br /> ❑Newtenewal <br /> Metrical Office/Business Name: m S <br /> Medical Office/Business Address: <br /> 1114k 0MI <br /> i tate Zip Code <br /> Contact Person: <br /> Phone Number: <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> CA I <br /> pity State Zip Code <br /> Permitted Treatment Facility Name:- <br /> Permitted Treatment Facility Address: COA. MOO: <br /> City State Zip Code <br /> List all employee names and titles authorized.to transport the medial waste(If more than 3,attach info): ` <br /> 1.Name: Title:� t i3 <br /> 2.NameA Ac <br /> Title: MIA <br /> 3..Natne; Title: <br /> A copy of this exemption and a tracking document s in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical wasterecords shall b ]kept on file at generator's or health care professional's fja lily ` <br /> Applicant Si ature. 11 A <br /> Date: <br /> l 1 <br /> Title: <br /> DO NOT WRITE. BELOW THIS LINE <br /> R.E.H.S. Application Approval:`a�.9-� -r` *- l� Date: ar..t5 <br /> Expiration Date: lL f�/A1_ Date Pain; , �1i% I�Cash or Cheek keceived By: <br /> H}ID.45-01 <br /> 11/19= <br />