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,v SAN JOAQUIN COUNTY <br /> EARoNmENTAL HEALTH DEPARTQI NT <br /> 600 E.Main Street, Stockton, CA 95202-3029 <br /> 09)468-3420■Fax:(209)468-3433- Web:www.co.san-joaquin.ca.us/ehd �,�, ' Aw �� U <br /> APP ATION FOR A LIMITED HAULING EXEMPTION' S/Tjr,; : tfj- <br /> TRTuMy IRr D"/IP hN 4 ufhthy HMQig(x1-P "Sur t tRdH'O Hl1cDDWDd10 DiEff 1-fit Act",thHI ' g <br /> conditions must be metW <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 followingW <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$70.00 fee to: <br /> San goaquin County Environmental Health Department <br /> Medical t aste Management Program 0 A-4j <br /> 600 E.Main Street, Stockton,CA 95202-3029 <br /> Medical Waste Hauler Information <br /> Et New ® Renewal <br /> Medical Office/Business Name: uivvC.Y Q Q i/i r <br /> Medical Office/Business AddressW 500 Tf iLill <br /> Cleve a d C) N 4412's- <br /> city <br /> i2-S'City State wip Code <br /> Contact PersonW L6e.0 `APS 1 A <br /> Phone NumberW <br /> Storage Facility Name: <br /> Storage cacility AddressW <br /> City State wip Code <br /> Permitted Treatment Facility Name: i 0-vi tD In C . Ma; <br /> Permitted Treatment c acility AddressW 15q l b <br /> h2K 256- <br /> City State wip Code <br /> List all employee names and titles authorized to transport the medical waste(If more than 3,attach info)W t C A rr,4£N <br /> 1.NameW TitleW <br /> 2.NameW TitleW <br /> 3.NameW TitleW <br /> A copy of this exemption and a tracking document shall be in IP SWHIs SIbsHsW4QDVV@W H while transporting medical waste. In <br /> DOGBWQ IH Iii P IJGfflDDNDsNHUWQ sh s KJh EMISUMs <br /> Applicant Signature i�rDateW ? /9 1 07 <br /> TitleW V`V" r te a= <br /> DO NOT WRI EBELOW THIS LINE <br /> R.E.H.S. Application ApprovalW DateW <br /> Expiration DateW / �/ Date PaidW ` / / -Cash or eq #W j L�� Received ByW <br /> EHD 45-02-001-web <br /> ionn003 <br />