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SAN JOAQUIN COUNTY ENOONMENTAL HEALTH DEPARTNOT Cf'b l I <br /> ' 600 East Main Street, Stockton,CA 95202-3029 -" igYhq�NT <br /> \ 420 Fax:(209)468-3433 Web: www.sJov.or /ehd R <br /> CMV- <br /> \Ci�oR��''� Te Phone: (209)468-3 <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION JAN 201, <br /> SAP JOgQUEN <br /> COJ <br /> To qualify for a "Limited Quantity Hauling Exemption"pursuant to the "Medical Waste Management Ac" TIMI' ng <br /> conditions must be met: <br /> The generator or health care professional generates less than 20 pounds of medical waste per week, transport 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 <br /> or a 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 <br /> to register pursuant to Chapter 4. <br /> Please complete the information below and mail with $77.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ❑ New `'Renewal <br /> Medical Office/Business Name: /r1 C'.0 1 n i eol 1 ? S (iC� Gi 1'( X, ✓/, <br /> Medical Office/Business Address: ), <br /> � i ► 0 -H- 7 <br /> City. State Zip t <br /> o/ D <br /> Contact Person: <br /> Phone Number: r U�Z 0 Q� -:S- <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> cc-f c,10 601 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Ve r i C- 6 <br /> Permitted Treatment Facility Address: e"�Cki <br /> - <br /> � <br /> C -- <br /> ity State Zip Code <br /> List all employee names and titles authorized to transport the medical waste (If more than 3,attach info): <br /> 1. Name: C✓ e ' P Aj,�/���'itle: 5kL�Qjv' C' <br /> 2. Name: - r r e " L- I Title: -tC <br /> 3. Name: ' C� Title: rVI(e L %wl& <br /> � t .�'cG't vt P _! roc. f o r � C Lt i LA,1? z�(� YK <br /> �� �-tC: S <br /> A copy of this exemption and a tracking do I! ent shall be in employee's possession at all times while transporting medical waste. I►� <br /> addition,all copies of medical yYas re ords shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: Date: <br /> Title: <br /> > , <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: 7 �_—Ao- �1 e-L . Date: OrI/!Z/1 I <br /> Expiration Date: �2/ fj I / ( Date Paid: /��/ _E-a4ror Check#-I S Received By: <br /> EHD 45-01 <br />