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M0 <br /> SAN JOAQUIN COUNTY Ati�►►� <br /> ENVIRONMENTAL HEALTH DEPARTMENT JUL 41 2010 <br /> 600 East Main Street, Stockton,CA 95202-3029 EI�V��O�h'utPiT HEALTH <br /> Telephone:(209)468-3420 Fax:(209.)468-3433 Web:www.sjgov.or Ol/ RVf1.tL.5 <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,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. Information Document if the generator or parent organization is a small quantity generator not required <br /> to register pursuant to Chapter 4. rA&:�00 tf--q <br /> Please complete the information below and mail with$77.00 fee to: kjt,0 btf`l <br /> San Joaquin County Environmental Health Department p"535 q�:iq <br /> Medical Waste Management Program Pc, q S S 7 <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Medical Waste Hauler Information <br /> XNew ❑ Renewal <br /> Medical Office/Business Name: E FAH-Adr-- ' I-A (/'S <br /> Medical Office/Business Address: Q / .4 t:, ' <br /> � <br /> C; State Zip Code <br /> Contact Person: SCC. <br /> 11 JAft*1 <br /> Phone Number: . <br /> Storage Facility Name: Ap <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: ' !' I <br /> Permitted Treatment Facility Address: a( 461',C <br /> EA r -,79S:75-- <br /> city <br /> ,75--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: t . Title: I-' <br /> 2.Name: X 11 W•i A kgul Title: <br /> 3. Name: L`71: .14 &-1¢'-fy Title: <br /> A copy of this exemption and a tracking document shall be ig employee's possession at all times while transporting medical aste. In <br /> addition,all copies of medical was records Ill file at generator's or health care professional''ss facili <br /> Applicant Signature: Date: I:�, 2 , <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: -7—/Z-1&.,- / <br /> Expiration Date: U Date Paid: / / 10 Cash o Check • I n I Received By: <br /> E• <br /> EHD 45-01 -7-7. D0 <br /> 11/19/08 <br />