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-------------------- -------- <br /> V 7 7 7,14 WVA <br /> /Ar//q <br /> pxye T <br /> SAN JOAQUfN COUNTYREIyED <br /> HEALTH DEPARTMENT ENVIRONMENTAL jA% 3 D 2014 <br /> 1868 East Razelton Avenue,Stockton, CA 95205-6232 NjaQUV.N COUNTY <br /> 138W SA EWRONME-NTAL <br /> (200)408-3. 420 Fax:(209)464-0 eb-.-v.Ywwsjgov,org/e. hd -M DEPARTMENT <br /> EAL. <br /> .APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for a Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management Act",the following <br /> conditions must be met: <br /> ,w <br /> The'generator or health care professional generates less than,20 pounds of medical waste per week,transports less <br /> th6n-20 pounds of medlaal waste at any one time,maintains a tracking docurnent pursuant to Chapter 6 and the <br /> generator or parent orgo.nization has on file one of the following; <br /> 1. Medical Waste Maaagemant Plan if the generator or parent organization is a large quantity generator or a <br /> 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 to <br /> register pursuant to Chapter 4. <br /> Please complete the informtton below and mail with <br /> San Joaqnn County Environmental Health Department <br /> Medicai-Waste Martaclement Program <br /> .-I W8 East Hazpfton Avenue, Stockton, CA 95205-6232 <br /> Medical Waste Hauler information <br /> 0 New Renewal <br /> Medical Officefflusiness Name. <br /> Medical Office/Business Address )9--)14 <br /> City State Zip Code <br /> Contact Person: <br /> Phone Number: <br /> .Storage Facift Name: <br /> Storage Facility Address: <br /> Gay State <br /> Permitted Treatment Facility Name: 3Ae-N4,� <br /> Permitted Treatment Facility Address: LOA <br /> 24i - <br /> CRY State Zip Code <br /> List all employee nam and titles authorized to transport the medical waste(11'more than 3,attach info): <br /> 1. Name: Inq-,t4- Title: <br /> 2.Nome: Title: <br /> 3. Narrie: Title'. <br /> A oopy Of this exemption and atfacking documentshall rte in employee's possession at all tines wt.iffelransporthig miadicalwaste. Iftadditloqaltropiesof <br /> medidal waste records 0611 be*kiiaon fila at gonerAtoes or health ore pr9fossional's facility. <br /> Applicant S-ignjiZturee- Date, <br /> Z-2 414C.)f-, <br /> Title: <br /> DO OT WRITE BELOW THIS LINE <br /> RENS Application Approval: Date: A-/ <br /> Expiratibn Dat4: It Date Paid: 1 I.1D114 Cash <br /> -yJWReceive0 13y: <br /> EHO 45.0151V12 APPLICATiON FOR A LIMITED QLANTM(HAULING EXEMPTION <br />