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SAN JOAQUIN (:OUNTY <br /> ENMNMENTAL HEALTH DEPART <br /> 600 East Main Street, Stockton, CA 95202-3 <br /> Tele hone: 209 468-3420 Fax: (209)468-3433 Web: wwIT,reh A 0ap ( ) A ) 2010 <br /> mac, <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION i��ctul,�col�r�T <br /> HE t I,Jr';Ci!i iriIT/L <br /> 1iyG-p�_ <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the "Medical Waste Management Act', the 1031 rowing <br /> conditions must be met: <br /> The generator or health care professional generates less than 20 pounds of medical waste per week, transport 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 Renewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: b� <br /> State Zip Code <br /> Ci�ty� <br /> Contact Person: <br /> Phone Number: ?4 0 (Ql C <br /> Storage Facility Name: — VVI tVi4 ISS - <br /> Storage Facility Address: - ��� �wuu <br /> City State Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: t� <br /> Ci State Zip Code <br /> city <br /> List all employee names and titles authorized to transport the medical waste (If more than 3, attach info): <br /> 1. Name: ttAOWir 61ionTitle: YYti <br /> 2. Name: Title: YYy(� t GPT <br /> 3. Name: 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 f�c <br /> Applicant Signature: <br /> 1�,(� Date: <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: w °rte car--- Date: t2./ P/-0 <br /> Expiration Date: \2./ 3 / Date Paid: \1) / �D Gas}rer.Eheck#: S 2-rJ Received By: <br /> EHD 45-01 <br />