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' PAYMENT SAN JOAQUIN COUNTY RECEIVED ^ 2 ENVIRONMENTAL HEALTH DEPARTMENT DEC 2 3 2013 • 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SAN JOAQUIN COUNTY (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd ENVIRONMENTAL HEALTH DEPARTMENT APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION 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, transports 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 $77.00 fee to: San Joaquin County Environmental Health Department Al PROV D Medical Waste Management Program l a 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Medical Waste Hauler Information ❑ New Renewal Medical Office/Business Name: r?n h 'f o e, e Medical Office/Business Address 1376 G E�- 57if• /Z7 5i'&-7 G/? w 9 /n City./ / // / State Zip Code Contact Person: Wei A&I,19 Phone Number: Z/55- 19ini - 1-;�Wo Storage Facility Name: Storage Facility Address: `-5- 6&t o-► Wiz/ City State Zip 06de / Permitted Treatment Facility Name: �� C / t`l Permitted Treatment Facility Address: r & City State Zip Code List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): 1. Name: 4-1rvb`st-!, _ 2- b Title: T A 2. Name: Title: TLIM 3. Name: 1NVIC l Wit? E2Zy\C Title: R 14 —' A copy of this exemption a d a tra i g docu e t shall be in employee's possession at all times while transporting medical waste. In addition,all copies of medical waste records sha I be k ' file at a rator's or health care professional's facility. Applicant Signature: Date: /off"/%1 PAYMENT Title: 6�51) RECEIVED DO NOT WRITE BELOW THIS LINE DEC 23 2013 V1 4 JOAQUIN COUNTY REHS Application Approval: -� t— Date: 'I/d�/1 NVIRONMENTAL --- ,AAALTH DEPARTMENT Expiration Date: it /It /4 Date Paid: kz-/ /17—�'> Cash onCheck : 9S LAI Received By. EHD 45-015/2/12 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION