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13-a-->6'7'7 AQurk �o �o SAN JOAQUIN COUNTY VIP 0"WILENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 c9 F.O (209)468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd Ft 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 AP'PRO` VE Medical Waste Management Program 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Medical Waste Hauler Information ❑ New 'K Renewal (� - I Medical Office/Business Name: l—1 nCI1 h .� t rlUdJ SC140) 1 ,D S t C-1L r-V1 Medical Office/Business Address a ey o td/ S W ce jj!j R dad 5 , IEZ2 P1 C-iq'- y tea-07 Cit ty State Code Contact Person: Phone Number: C�o - Storage Facility Name: �- /J ' - _VNO S�,vt,�r�� /�rS C ' f� 4w Storage Facility Address: -(� - 1�,ry State Zip Code nP-4-1 Permitted Treatment Facility Name: S Permitted Treatment Facility Address: r 0-I UV1 L® City State Zip Code List all employee names and titles authorized to tra sp._ort/the medical waste (If more than 3, attach info): �! �/ 1. Name: 4q Title: CI- A)C4,r5(a, 2. Name: 'R e-.n P e- O 1 /3 P4 i e N . LVIAVI Title: j/Syr l r (4- CS�- 3. Name: )+c10 eHhe ,AAUr.�1� L✓/1.� Title: ;s �r'�[� A./tA-cs Karen /tit r-k�- AJ L5?5�ri G /l�u r5�- A copy of this exemption and a tracking ocument shall in employee's possession at all times while transporting me ileal waste. In addition,all copies of medical waste records shall be kept on file at generator's or health care professional's facility. Applicant Signature: C��trhRJ Date: Title: DO NOT WRITE BELOW THIS LINE RENS Application Approv � Date: A/ /l»3 Expiration Date: 1 /13-Date Paid: / -7 / l3 Cash or Check#:1490-2�45 Received By: l EHD 45-01 5/2/12 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION