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SAN JOAQUIN COUNTY <br /> 4.-.. ._ _ ENVIRONMENTAL HEALTH DEPARTMENT <br /> F. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ...... .P (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> FOR <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, transports 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 or a <br /> 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 to <br /> 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 "PP ROV <br /> Medical Waste Management Program �4 <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Medlcal Waste Hauler Informatlon <br /> ❑ New Renewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address 0 <br /> 0 <br /> City State 'Zip Code <br /> Contact Person: Ar VIdA <br /> Phone Number: o I1aw <br /> Storage Facility Name: Ir�,t(�P:� �► <br /> Storage Facility Address: "�U1fGtyt[[� Cit � — <br /> City State Zip Code <br /> Permitted Treatment Facility Name: L <br /> Permitted Treatment Facility Address: <br /> City State Zip Code <br /> List all employee n "esanda tit,es authorized tQ transport the medical waste (I�more than 3, attach info): <br /> 1. Name: !i tJ�1� Title: <br /> 2. Name: i Title: <br /> 3. Name: A[ 0 Title: WIM <br /> A copy of this exemption and a tracki document shall be in employee's possession at all times while transporting medical waste. In addition,all copies of <br /> medical waste records shall be kept fil t generator's or health&acre professional's facility. <br /> Applicant Signature: Date: <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval 11C.. y.�' C' �J�..V .r. __ Date: t 21AIL7� <br /> Expiration Date: / Date Paid: �al N//O�' Cash or"heck 1 Received By: <br /> EHD 45-01 5/2/12 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />