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alp?y • � , SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ~`�.'•/!j- 600 East Main Street, Stockton, CA 95202-3029 • �, i . Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd 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,transport 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: pAyMF-NT San Joaquin County Environmental Health Department RECEIVE® Medical Waste Management Program 1 7 2009 600 East Main Street, Stockton, CA 95202-3029 SEP Medical Waste Hauler Information SAN JOAQUIN COUNTY VIRONMENTAL New ❑ Renewal HEALTH DEPARTME Medical Office/Business Name: Lincoln Uyt,�IeA Schoolt7iS"1YiC,�d Heald) Sery ('(�S 007 Medical Office/Business Address: Qal n W-s-t 5uzc,!n (ZocAU ljd11' 1�r-f�tc�, cit 9s�01 �0,1q City State Zip Code Contact Person: eu-e-iu lder' 0,15e,on 000� Phone Number: ac�- ,q��,�-7�� o209•953.g-7aT Storage Facility Name: ijkl oaksc:,�, 4Ss� Storage Facility Address: leio jo w. City State Zip Code Permitted Treatment Facility Name: S+f-rie,te,1e1 11vC/CI�kAQn -Bks Permitted Treatment Facility Address: 5e 1 s 61+0n I City State Zip Code List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): 1. Name: E e.( f lA W Title: &- -)n0o` lQu.ILSe. 2. Name: RtyiLye O'2y-i Q r LV N Title: St n onl p,3ulrse 3. Name: 1 iyy,r� Sc VI rd-1' Title: Sefy►ce-5 14. 5GLndeS 0,re_c4Tir-, Ch;Id LOeIFc,re ' A ncla-ce_ A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In addition,all copies of medical as a records shall be kept pP MVnk at gen ator's or healthcare professional's facility. A lic nt1Si natu e: �Y// Date: 6 -1 —D 1p —6 Title: DO NOT WRITE BELOW THIS LINE R.E.H.S. Application Approval: CXA�.— Date: 1-113/ Expiration Date: / / Date Paid: 17 /Dq Cash Check 3D-D-0 ( Received By: EHD 45-01 11/19/OR