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�o SAN JOAQUIN COUNTY PAYMENT RECENED - -� ENVIRONMENTAL HEALTH DEPARTMENT '• 1868 East Hazelton Avenue, Stockton, CA 95205-6232 DEC 19 2013 �q�fFsR��P (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd &kNJOAQ,INCOUNTY 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, 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. 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 API'' OVE Medical Waste Management Program '. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Medical Waste Hauler Information ❑ New /Renewal Medical Office/Business Name: o-F -Phz Medical Office/Business Address ,.,5-1r�r kficyt ri4 �(S"21 I City State Zip Code Contact Person: Gi-c, `favor Phone Number: 209 946- 2-`I-6 Storage Facility Name: Jk A s W-,4-,S Of pa-i ,c Storage Facility Address: '75- I 12,A- city ,A-City 5+oG k•t,,,N State G,q Zip Code Permitted Treatment Facility Name: �i G Permitted.Treatment Facility Address: `w;-F4 re Ao l_1 !7 37 2-2— city -2city State Zip Code List all employee names and titles authorized to transport the medical waste(if more than 3, attach info): 1. Name: Dr. ?Wel Title: j—� A _ 2. Name: r`4--fin Title: c ., ^f 3. Name: Y�reA i n e.^ Title: -,Ay -w 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 waste records shall be kept on file at generator's or health care professional's facility. Applicant Signature: Date: k2- Title: ,, DO NOT WRITE BELOW THIS LINE REHS Application Approval: 'Yy:.``k' - ` �- Date: /iq /r3 Expiration Date: 12- /'�31 / Date Paid: 12--/ /T/ /-3 Cash or eC"e : Received By: EHD 45-015/2/12 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION