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J R` "d-1 <br /> # <br /> t PAYMENT <br /> SAN JOAQUIN COUNTY RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT DEC 2 3 2013 <br /> }' 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> SAN UOAOUIN COUNTY <br /> (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualifpfor 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 /> Nnerator 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$777.00 fee to: <br /> San Joaquin County Environmental Health Department t-i[ PRD D <br /> Medical Waste Management Program <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Medical Waste Hauler Information <br /> ❑ New Rene*41 <br /> Medical Office/Business Name: <br /> Medical Office/Business Address <br /> CitState Zip Code <br /> Contact Person: I <br /> Phone Number: <br /> Storage Facility Name: <br /> Storage Facility Address:. <br /> City State Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: 1 <br /> C tete Zip Code <br /> List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): <br /> 1. Name:. Title:_ <br /> 2. Name: Title: <br /> 3. Name: Title: <br /> A copy of this exemption and a tracking dog, ntentshall be In employee's possession at all times while transportln9 m�e lcal waste. In addition,all copies of <br /> medical waste records shAll be k t Is a generator's or health care professional's facility. <br /> Applican - i' ` ;�tlre: Date: l 1 3 ! PAYMENT <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE DEC 212013 <br /> SA JOAQUIN <br /> REHS Application Approval: _ ( �� �L4� Date:/ ETr <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> Expiration Date:-1/-31 /1 Date Paid: Cash/�31 3 Cash o heck#:) 9Kt dl Received By: <br /> EHD 45-015/2112 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />