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Aqu r nr [r�yLr SAN JOAQUIN CO TY PAYMFNT �: •.o N:. < ENVIRONMENTAL HEALTH DEPARTMENT RECEiVED ° 1868 East Hazelton Avenue, Stockton, CA 95205-6232 DEC - 5 2013 �4<<FOR�`P (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd SAN JOAQUIN COUN71. H�TM DEpM NT 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 register pursuant to Chapter 4. Please complete the information below and mail with $77.00 fee to: San Joaquin County Environmental Health Department AP�3�®�T1, Medical Waste Management Program 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Medical Waste Hauler Information ❑ New Renewal Medical Office/Business Name: 4 �� SLP'j y Medical Office/Business Address Y J Q. tot r City t Zip Code Contact Person: �H 'y /�.f"A Stat Phone Number: Storage Facility Name: Storage Facility Address: Off"", tff L City State Zip Code Permitted Treatment Facility Name: O t,Il.lZ041 Gni •<Ca jib t Permitted Treatment Facility Address: City State Zip Code List all employee narrAsand titlg�uthorcl to transport the medical waste If more than 3, attach info): 1. Name: �R (I q Title: N 2. Name: Tficau flVM Title: W t4 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 nerator's or health care professional's facility. f Applicant Signature: Date: Title: 7.P hn0i► , DO NOT WRITE BELOW THIS LINE REHS Application Approval: , ,� Ca r Date: iZ 10/1 Expiration Date: 17- /-29k / Date Paid: /215- Cash or Check#: 2-53 5"7 Received By: EHD 45-015/2/12 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION