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SAN JOAQUIN COUNTY I / f <br /> -= 2 ENVIRONMENTAL HEALTH DEPARTMENT <br /> • 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> (209)468-3420 Fax: (209) 464-0138 Web:www.sjgov.org/ehd <br /> �IFOR <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, transports 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 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 information below and mail with $77.00 fee to: <br /> San Joaquin County Environmental Health Department APPRQ`7- D <br /> Medical Waste Management Program <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Medical Waste Hauler Informatlon <br /> ❑ New `,Renewal r <br /> Medical Office/Business Name: <br /> Medical Office/Business Address <br /> City State Zip Code <br /> Contact Person: <br /> Phone Number: <br /> Storage Facility Name: 1� �✓ <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: <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: ('' �� C.k Q 1D( Title: <br /> 2. Name: Title: <br /> 3. Name: Title: <br /> 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 <br /> medical waste records shall b ept on file at rator's or health care professional's facility. <br /> Applicant Signature: Date: i'1-a ca— l� <br /> Title: <br /> (� DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval:—At, L Date: _Lq.�ID I <br /> Expiration Date: JIL /..51 /13 Date Paid: Ial l'U l la Cash or hec &6-610 Received By: <br /> EHD 45-015/2112 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />