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oPQ'u rN ° SAN �JOAQUIN COUNTY • v <br /> �.•'. •.oG <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N. < <br /> � �. 600 East Main Street, Stockton, CA 95202-3029 DEC 12 2011 <br /> (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd ENVIRONMENT HEALTH <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION PERMIT/SERVICES <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 n�irsuant to Ch�ntar d. <br /> r, -r-1-1 . <br /> Please complete the information below and mail with $77.00 fee to: 4 : <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 600 Fast-MainStreet,-to_ckton,CA-95202-3.029 <br /> Medical Waste Hauler Information <br /> ❑ New XRenewal CgAW Avas 1/ <br /> Medical Office/Business Name: Onh-v W44wf <br /> Medical Office/Business Address C <br /> v+ <br /> Cit State Zip code <br /> Contact Person: P&VIA IQ M a- U <br /> Phone Number: . <br /> Storage Facility Name: o4t, M11P.j <br /> Storage Facility Address: -Tt,('(MLA/ <br /> City State Zip Code <br /> Permitted Treatment Facility Name: ( cw <br /> -Pari 1�'ttod Treatment Fccilit;Address: <br /> City State Zip Code <br /> List all employee nameA and titles authorized to transport the medical waste (If more than 3, attach info): <br /> 1. Name: A Uyu (k(uh.A Title: lht� <br /> 2. Name: WwvA GrowKi-- Title: m <br /> 3. Name: W cis 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 addition,all copies of <br /> medical waste records shall be kep on file at generator's or health care professional's facility. <br /> Applicant Si ture: � lt�tL` Date: <br /> Title: L n!2tW <br /> DO NOT WRITE BELOW THIS LINE <br /> RENS Application Approval: Date: _/A�- <br /> Expiration Dater V / 91 77 <br /> / � " Date Paid: / 114 Cash oreheck 11-1 Received By: _ <br /> EHD 45-0111/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION <br />