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- ---------- 6508490472 EMS Services ENVIRONMENTAL MANAGEMENT— 08*a.m. 12-13-2010 2/3 W, ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street,Stockton, CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www I , I" COPY ,C��77,7 sjgov.orglehd -i,1..4.R?, 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: 1. Medical Waste Manageinent 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. RECEIVED Please complete the information below and mail with$77.00 fee to: San Joaquin County Environmental Health Department DEC 13 2010 Medical Waste Management Program 600 East Main Street,Stockton,CA 95202-3029 ENVIRONMENTAL HEALTH Medical Waste Hauler Information PERMIT/SERVICES Ej New ,Renewal Medical Office/Business Name: u9,qr+MeAfr ©jc V1FT-a#-,2,oyj 61�rq,* Medical Office/Business Address: 3 IV e I /tl i rt v d.4 ,4 V,97 e tq 10 x A --t 41 L3eq City State Zip Code Contact Person: A.,-ls-5 J?,.,b j A( y Phone Number: 5� q 11 It 5-000 X 6j--1 95— Storage Facility Name: 45AALC AS A-AaVE Storage Facility Address: City State Zip Code Permitted Treatment Facility Name: IS4+6/*/GV CZ r- Permitted Treatment Facility Address: '-A4-IZS ul. w ice- City State Zip Code List all employee names and titles authorized to transport the medical waste(If more than 3,attach info): 1.Name: 61--A I I tr 4;/7 Title: —k At P 2. Name: ,5ike"a�&A IZAFid Title: JQ -AJ -P 3. Name: Al *r ivr M04fj-c-a Title: t4-4401v, 0 r-ja *ri,+If- A " A copy of this exemption and a tracking document shall 410 employee's possession at all times while transporting medical waste. In addition,all copies of was medical records sho.e, t generator's or health care professional's facility. F-1 1"P� 7* Applicant Signature:7�-�,.9.��(,---'--,------,4� Date: Title: ?r ca DO NOT WRITE BELOW THIS LINE R.E.H.S. Application Approval:a -ADate: L2.-/!Ad—t) Expiration Date: M Date Paid: C�V �k#: 19q'-149-1 Received By: EHD 45-01