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U �o SAN JOAQUIN COUNTY s EN-*ONMENTAL HEALTH DEPARTIV*Ir-� ENT 600 East Main Street, Stockton, CA 95202-3029 `P Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd b t.� 1 1 21707 q��FOR UIN COUNTY APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTS oAQVIRONMENTALTAL HEALTH DEPARTMENT 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,transport 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 72.00 feet San Joaquin County Environmental Health Department Medical Waste Management Program 600 East Main Street, Stockton, CA 95202-3029 Medical Waste Hauler Information Q New Renewal Medical Office/Business Name: �4:4-J,Tig- g6b,(04QgV el gz- GRP, Medical Office/Business Address: // V ► Jnr', U/ S ,-c 1,5- r �Z-006 i ,5- oAi A- S=�L:a City State Zip Code Contact Person: U. K,I 9,> Phone Number: Z d � Storage Facility Name: A b UA—,OC ZE C> Zs14 An 0- SIU TZ—' Storage Facility Address: 1031 Sv %aF t'R 41 v 7— L c, D l /-Ss- .S Y�: a City e State Zip Code Permitted Treatment Facility Name: S'P P- / C CLED WA-S72E 7r,,C- t S Permitted Treatment Facility Address: 9,z—t/ 9 7.S W-/+ / 1= a c .O. 'C f o C G R 1>6 UA, CA- 7 7® City State Zip Code List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): 1. Name:( ,t<, o r-/+X4 S?' b 7-- S,(' Title: A-R"Q-- 2. Name: v jJ2 c,A L Title: t R `1— 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 general is or health care professional's facility. Applicant Signature: /�, Date: ) 2 3 Title: 'K cJ tJ l -C-, ,o DO WT WRITE BELOW THIS LINE R.E.H.S. Application Approval: 1 Date: Expiration Date: / 3/ / ate aid: , / `� / 6� heck 2� Received By: EHD 45-01 10/02/07