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SAN JOAQUIN COUNTY <br /> EAkONMENTAL HEALTH DEPARTONT PAYMENT <br /> (� ={ RECEIVED <br /> 600 East Main Street, Stockton, CA 95202-3029 JAN _5 <br /> oP• Telephone: (209)468-3420 Fax: (z09)468-3433 Web: www.sjgov.org/ehd <br /> ��tFOR , 2011 <br /> SAN JOAQULN COUP. <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION ENVIRONMENTAL <br /> HEALTH DEPAR7VENT <br /> To qualify for a "Limited Quantity Hauling Exemption"pursuant to the " %6W PYment 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. Inforination 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 /> E]New LP <br /> M Renewal 1 A <br /> Medical Office/Business Name: IV OF TNS AC: I f�1 C <br /> Medical Office/Business Address: -3W FA e 1 r l C AVE <br /> TbCK='4lN <br /> City State Zip Code <br /> Contact Person: A s i-1 <br /> Phone Number: 2 0 - 996 -15 6 5 2 0 5 - 6 10- 61 qS <br /> Storage Facility Name: _ 1,1W 1 a'r TKF, LC If/C- <br /> Storage <br /> C.Storage Facility Address: I"I 51 C3 i1�S 1 1z1b <br /> S e lLTa C t- 9,-Lo <br /> City t State Zip Code <br /> Permitted Treatment Facility Name: SM KI CYC L61 <br /> Permitted Treatment Facility Address: �► S i�!F T A VE <br /> 6 e ; r7z� <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: I'EI?-E N 1 CA 8;> ,nJ0.1 Title: rOc,u L-T Y <br /> 2. Name: AdaFLY, L e" Title: FA-c y LTY <br /> 3. Name: I LL IAM Ka N0& Title: F(AC U L-rY <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical waste records shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: AoA Date: )'2 1IIL-0 10 <br /> Title: S yi�cl gz�LL W4141APA12M -rt.l' <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: _/d,5T U <br /> Expiration Date: Date Paid: / 5 / C-Rsl--ar Check#: lb Received By: Vl-&' <br /> EHD 45-01 <br />