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RETE ANT <br /> ED <br /> /h4'31 a SAN JOAQUIN COUNTY <br /> AN <br /> 2 2011 <br /> ENVIRONMENTAL HEALTH DEPARTMENT saNJoq <br /> 1868 East Hazelton Avenue, Stockton,CA 95205-6232 HEENVVi 40 MENjq�71' <br /> Cn Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd TIAL <br /> i i'r.tjEiei <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 /> 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 Z <br /> 1868 E.Hazelton Avenue, Stockton,CA 95205-6232 <br /> Medical Waste Hauler Information <br /> ❑ New [3 Renewal AIPRr�V <br /> Medical Office/Business Name: <br /> L ( chool District/Health Services <br /> Medical Office/Business Address: 1305 E. Vine Street <br /> Lodi CA 95240 <br /> City State Zip Code <br /> Contact Person: Susan Atkinson, Admin. Secty. <br /> Phone Number: 209-331-7075 <br /> Storage Facility Name: C1eanHarbors <br /> Storage Facility Address: 7850 South R.A. Bridgeford St. <br /> Stockton CA 95206 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: save as above <br /> Permitted Treatment Facility Address: <br /> City 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: see attached list Title: see attached list <br /> 2.Name: Title: <br /> 3.Name: Title: <br /> A copy of this exemption and a trockingJacumunt shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of need' waste records shall be t on file at generator's or health care professional's facility. <br /> Applicant Signature. Date: bi11 n <br /> Title: Coordinator, Special Services/Health <br /> DO NOT WR�TE BELOW THIS LINE <br /> R.E.H.S. Application Approval: �-�G — �(/ , Date: n%/0Vl _ <br /> Expiration Date: LZ,_i Date Paid:_/ / Z ;/T Cash or Cheek k 1�309'j-71 Received Bv: <br /> E11D 45-01 <br /> 111:191;08 <br />