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SAN JOAQUIN COUNTY / ENV NMENTAL HEALTH DEPARTM10 � 60v East Main Street, Stockton, CA 95202-3029 \e A/ COPY Telephone: (209)468-3420 Fax: (209)468-3433 Web: WNvw.sjgov.org/eh � 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, transport 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: i. 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 i 20"10 Medical Waste Management Programll.. 600 East Main Street, Stockton, CA 95202-3029 SAM JOAQUIN rOUNIY Medical Waste Hauler Informatio '','jAB'`TAL ��IaLTH DEpAt�TtvtEtvT ❑New ,Renewal Medical Office(/Business Name: C.C ?ir.� c, Medical Office/Business Address: I (v d. City State Zip Code Contact Person: k -y� /- ( , A Phone Number: 2 Storage Facility Name: w�— Storage Facility Address: City State Zip Code Permitted Treatment Facility Name: (-)"U d- � J 4� J�` o S c--Q S-�A` Permitted Treatment Facility Address: 3 ? 3 �' 1-{ l` I( 9,0 0-1 PO a City State Zip Code List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): 1. Name: 4-tkA- L Le-_& Title: 2. Mame: Title: 3. Name: Title: 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 medic�wastrecords�all kept onfile at-gtuerator's or health care professional's facility. Applicant Signatur Date: 10 Title: AA SV GLicac` DO NOT WRITE BELOW THIS LINE R.E.H.S. Application Approval: _ ky-•-Clt, Al— Date: /y/ Expiration Date: l'Z-1 Date Paid: / / Cash or ech-#': Received By: EHD 45-01