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SAN JOAQUIN COUNTY IS LNL M <br /> ENVIRONMENTAL HEALTH DEPARTMENT DEC - 9 2011 <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> (209)468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd ENVIRONMENT HEALTH <br /> cqJ• PERMIT/SERVICES <br /> /POR <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 /> rPnister pursuant to Chapter 4. <br /> Please complete the information below and mail with $77.00 fee to: FILE <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> _fiDREast_Main-Sfreetr-_to-ckton,_CA_9.52D2-3D29__ <br /> �Renewal <br /> Medical Waste Hauler Information <br /> 11New <br /> 1 L <br /> Medical Office/Business Name: �n TGf r G! 0�_4 <br /> Medical Office/Business Address 10 <br /> City State Zip Code <br /> Contact Person: <br /> Phone Number: Z <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: q CK <br /> Z — <br /> SO <br /> City stale Zip Code <br /> List all employee names and titles authorized to transport the medical waste (If more khan 3, attach info): <br /> 1. Name: n Title: V <br /> 2. Name: Title: <br /> 3. Name: / Title: <br /> A copy of this exemption anda trackin 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 Ile at generator's or health professional's facility. <br /> Applicant Signature: Date: 7 ho / <br /> Title: cxr' <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: ��M.__ Date: 12/ 115/ 11 <br /> Expiration Date: / tZ Date Paid: (�/ / Cash orheck _ Received By: <br /> EHD 45-01 11/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION <br />