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`QU1N�. <br /> EASAN JOAQUIN COUNTY �� p <br /> ONMENTAL HEALTH DEPARTAW' T <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> �., Telephone:(209)468-3420 Fax: (209)468-3433 Web: www.sjgov.org/ehd DEC1 7 2008 <br /> .or /ehd <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTI SRO NMENT HEALTH <br /> EN JIFti_i�iY.�;l°,;•�11CFS /SE <br /> P&;4�la6fVfor a"Limited Quantity Hauling Exemption"pursuant to the "Medical Waste Management Act", the following <br /> conditions must be met: rt <br /> The generator or health care professional generates less than 20 pounds of medical waste fer U n p �pan 1 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 $77.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ❑ New [94enewal <br /> Medical Office/Business Name: &kA ljpct arr- <br /> Medical Office/Business Address: <br /> SZ <br /> City State Zip Code <br /> Contact Person: «� <br /> a <br /> Phone Number: <br /> e taR •...P 1 <br /> 7`1 ;737 <br /> Storage Facility Name: '"gym umf 'go vee <br /> Storage Facility Address: r?�J� 1-0. (,,,-4F 11(2 <br /> Sfor-tc 4-rl[► Cdr 7 <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 ore than 3, attach info): <br /> In <br /> 1. Name: Z_,,c Title: Ac � ,r�✓,. <br /> 2. Name: 5V ZTitle: , <br /> 3. Name: yrs_%� /a Z 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 /> Applica Signature: Date: ' <br /> Title: 1/1 ��,,®,�� <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: �,�,�CS�,�-_---_ p,p, Date: Z./ t7 <br /> Expiration Date: 12-1 3 / `�Date Paid: / �� / C-aslrnr hec 1 I�� Received By: <br /> EHD 45-01 <br />