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ViN �°P�• '''�'o SAN.TOAQUIN COUNTY 'G + ENVTRONMENTAL HEALTH DEPARTMENT ,, y 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202-2708 ., 11 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/eh Q�IPOR�` APPLICATION FOR A LIMITED QUANTITY MAULING 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. Please complete the information below and mail with$70.00 fee to: San Joaquin County Environmental Health Department PAYMENT Medical Waste Management Program RECEIVE D 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 DEC — 3 2004 Medical Waste Hauler Information SAN JOAOUIN COUNTY New F-1RenewalENVIRONMENTAL 1-IFAL.TH DEPARTMENT Medical Office/Business Name: 1• AY t*,, We*AaAk(A" S6t-y%�cD Medical Office/Business Address: t-+-+( W, ma-'ra , s vhf- it 1`O City State Zip Code Contact Person: '�� M�ci%t.! L Phone Number: y.? )-2 7 3;L Storage Facility Name: n4mw, Hf t#46r e -�i-V14�4 Storage Facility Address: — 1 �� . . t,c.�_�j A+w'�L. � 11V City State Zip Code Permitted Treatment Facility Name: 2ald, S ✓1 c Permitted Treatment Facility Address: /1 ��r 6-1611k 4r,k Cys !� /2 City State Zip Code List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): 1. Name: Fj euty.) semwrof - Title: 1W 1. 2. Name: Sol.,! T>EM59tJ Title: NcLojA*% Jt�� 3. Name: �k o k kms, Title: Rcsar,�arcs 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: 1,1 Title: Gc ✓n 6 61!!�- � DO N T WRIT BELOW THIS LINE R.E.H.S. Application Approval: Date: I/L/ /65' Expiration Date: �/�/Date Paid: /� / 3 /�Cash or heck#. /104, Received By: �1✓. EHD 45-02-001 10/7/2003