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Ac,u�N SAN JOAQUIN COUNTY • U99091) <br /> ENVIRONMENTAL HEALTH DEPARTMENT DEC 2 3 2011 <br /> 600 East Main Street, Stockton, CA 95202-3029 ENVIRONMENT HEALTH <br /> c P (209)468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd VEIIMITISERVICES <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 <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ❑ New `j�Renewal <br /> Medical Office/Business Name: mtd-c&f 1A <br /> Medical Office/Business Address %/2/ W. V t <br /> L4peu CA <br /> City State Zip Code <br /> Contact Person: Je_r►rt c ' <br /> Phone Number: <br /> Storage Facility Name: <br /> Storage Facility Address: lo 31 iY <br /> City Lodz State Cif Zip Code <br /> Permitted Treatment Facility Name: moi' <br /> Permitted Treatment Facility Address: l © i <br /> h ett n d�o Cl 17,41S-7 7 <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste af more pan 3, attach info): <br /> 1. Name: den w-A,-- RQ,.4,k`sp Title: 4 <br /> 2. Name: Title: <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 addition,all copies of <br /> medical waste records shall be kept on file at generator's or health care professional's facility. <br /> Applicant Sign ture: �� Date: A& it <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: p Date: t/b3, <br /> Expiration Date: l7/ /� Gy) <br /> heck <br /> / �� Date Paid:�/VI�� Cash or : ni Received By: _ <br /> EHD 45-0111/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION <br />