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EI&RONMENTAL HEALTH DEPARTNOT <br /> 600 East Main Street,Stockton,CA 95202-3029. <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant t6the 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. <br /> Please complete the information below and mail with $77.00 fee to: pYMENT <br /> p1 <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program SUN 1® 2011 <br /> 600 East Main Street, Stockton, CA 95202-3029 Quitl C000 <br /> Medical. Waste )FIauler Information SAS%V19" ENTMEwT <br /> HEALt ,DEPAA <br /> [1 New ❑ Renewal <br /> Medical Office/Business Name: CzTY C)F 5—%ONT7 -0" P0LTCF 1)E99�Z"A <br /> Medical Office/Business Address: L TP,Im U 5*4A glz� <br /> CA C152-10 <br /> City State Zip Code <br /> Contact Person: L--r c- .�"iKriT '5W-9- YIA< V 1A -� <br /> Phone Number: <br /> Storage Facility Name: 0-1T C) DEP),P\-7Mt <br /> Storage Facility Address: c� ST <br /> City State Zip Code <br /> Permitted Treatment Facility Name: ,r <br /> Permitted Treatment Facility Address: G ` �r ZZG v' <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.L T►.x_-)F,,-2TQ6QAVE- C-LPeM Title: <br /> 2.Name:STA OLLY Title: <br /> 3.Name:P)OM'j P Llv 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 <br /> addition,all copies of medical w ste records shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: C Date: <br /> Title: <br /> DOZL;WDWL_,.• <br /> BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: fc. / b /1) <br /> Expiration Date: /'3i� Date Paid:, 10 Cash Check#: 1 D®�3 Received By: j!;0L <br /> UM 45-01 <br /> 11/19/08 <br />