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avieaitvur TUN 1Z:is rwx ZUV4b6s4sj Sic $HD 10002/002 o u-J ,•,.�>:.' _..��o SAN JOAQUIN COUNTY Q; tie;„,- A v l We IRONMENTAL E LTH DEPARTMENT a;1;!'j/ _ 600East Main Street,Stockton,CA 95202-3029 ;P Telepimne:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd - 3 2007 APPLICATION FOR A LIMITED QUANTITYULING EXEM „ To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management A t",f the'' li ES T fj 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 fee to: 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/Bushmess Name: 14eC4 ")3Ae.0 V1 Nuolo, I c, Jit Civ Medical Office/Business Address: � P.-C-s ec.-f 1 r k 6k ,Sfe. i 12 branch® f or'dov-4 r.4 9s"&Ica City State Zip Code Contact Person: Gtre o ? VC?r Phone Number: Storage Facility Name: //h 4 cL/r Je,-o�eJ Storage Facility Address: 3C)3.s 140.0 cel Fri k Pr S iia 2oinc/70 r VVC4 15� '70 City State Zip Code Permitted Treatment Facility Name: Sin .14cl Permitted Treatment Facility Address: .2 k1 6 / /+✓° ®c f:.-fh by 4011-e— PrP -77/ _ 600tj City State -Zip Code List all employee names and titles`authorized to transport the medical waste(If more than 3,attach info): 1.Name: M J2s�6LuA- G--� Title: L. 1d 2. Name: Title: L%U -N 3.Name: Pq\A rA Ck CA Title: r�, - A copy of this exemption and a trac g document shall be in employee's possession at all times while transporting medical waste. in addition,all copies of medical w e records shall be kept on file at generator's or health care professional's facility. Signature: & C— Applicant ® Date: f 0 2 ,l� Title: DO NOT W- 1TE E ,, THIS .LINE R.E.H.S.Application Approval: Date: /Op�- Expiration Date:L! :50 te Paid: ® ash or Check#: Received By: END 45.01 10/02/07