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SAN JOAQUIN COUNTCop <br /> Y <br /> LE <br /> E ONMENTAL HEALTH DEPART41 <br /> i 600 East Main Street, Stockton, CA 95202-3029 -1 V!= . <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd <br /> 23 2010 <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIO 1 VjF?0, N <br /> NEALOUNTY <br /> T i�)E EN <br /> i -rAL <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management Act",the� �8iir[g <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 /> / <br /> ❑ New M'nenewal <br /> Medical Office/Business Name: Lr•1 ' 1� VI,Q �C r�frCl ! <br /> Medical Office/Business Address: OAK_FP-EC-t3j VD , i-I e <br /> v QW31 <br /> CityState Zip Code <br /> Contact Person: <br /> Phone Number: 2X1' <br /> Storage Facility Name: NA06 L:prUI(tiC,t u- <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: S l OyIf-- <br /> Permitted Treatment Facility Address: - 6-0 <br /> �" <br /> CAC<W4- --0, <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): <br /> 1. Name:� C � • Title: <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 <br /> addition,all copies of medical waste record s a e kept on file at generator's or health care professional's facility. <br /> (i (�0,�ou) <br /> Applicant Signature. ' Date:: <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval:` Date: 17- <br /> Expiration Dater/'SI Date Paid: `I— / 23 / u Gash=Fm Check#: 3`�3 5 Received By: <br /> EHD 45-01 <br /> 11/19/08 <br />