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O AQ V!ty. C, SAN JOAQUIN COUNTY • D ENVIRONMENTAL HEALTH DEPARTMENT Q "a 600 East Main Street, Stockton, U2 -.3 0 SAN Y3 2012 (209) 468-3420 Fax: (209)464-0138 W b: go ! hd ENVIRONMENT HEALTH APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION PERMIT/SERVICES 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. ollowing: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 Medical Waste Management Program 600 East Main Street, Stockton, CA 95202-3029 Medical Waste Hauler Information ❑ New Renewal rr J p Medical Office/Business Name: i ti e o ( S ,r / t'✓%C65 Medical Office/Business Address - '15f-oGilL 9�5-3Z O 7 City State Zip Code Contact Person: e LIPA-1 c/ Phone Number: Storage Facility Name: 0 11 Storage Facility Address: � City "ta+p Jap Code Permitted Treatment Facility Name: ti 0 Permitted Treatment Facility Address: - G (n City State Zip Code List all employee names and titles authorized to transp rt the medical waste (If more than 3, attach info): - - -9.-lame:- — o, A - _ . . - - Title:- r4VO �,L- e_- - - - 2. Name: t'lio? Title: , 3. Name: vc Mal' Title: � Yt 2� " � A copy of this exemp ion and a trackin f ocument shall be Ir/e pio e s possession a aIT time§W ile transporting medical waste. In addition,all copies of medical waste records shall b k pt n file at generator's or h alth care ofessional's facility. Applican i nature: /Date: l R— Title: DO NOT WRITE BELOW THIS LINE REHS Application Approval: i heck : Date: Expiration Date: Z/ ;k / t Z Date Paid: ' / / 1 Cash or he :J Z 1`� �3 Received By: EHD 45-01 11/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION