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SAN JOAZIN COUNTY <br /> Q.- - -' ENVIRONMENTAL HEALTH DEPARTMENT <br /> F. <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> • e�••:' �c (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd I`7- j t��•,-1 O(J a q ©^ g <br /> ��FOR <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, transports 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 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 $77.00 fee to: RE'yMEN'r <br /> EKED _ <br /> San Joaquin County Environmental Health Department APPROV JAN <br /> Medical Waste Management Program 2013 <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 &"�OAQupuCGU <br /> HE41_N D tj4 rrAn ® N <br /> Medical Waste Hauler Information <br /> ❑ New Renewal <br /> Medical Office/Business Name: { _ <br /> Medical Office/Business Address s-0 q?— 1�4 1 ivW �t- I qZ�q <br /> Las A lzs 6A <br /> CityState Zip Code <br /> Contact Person: K—:L ws l<as <br /> Phone Number: tfn & -5 66 -o—Ki- 12.2.S' <br /> Storage Facility Name: S Gt I v "O'de' ) <br /> Storage Facility Address: <br /> CityState Zip Code <br /> Permitted Treatment Facility Name: 5 Ce tff e'e— r. <br /> Permitted Treatment Facility Address: to k 54,LLLe- At <br /> Cmc ,,r. <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: 5 e rf¢, f �� /z� Title: <br /> 2. Name: Title: <br /> 3. Name: 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 addition,all copies-of <br /> medical waste records shall be kept on file at erator's or 1 re professional's facility. <br /> Applicant Si nature: Date: /Z Z�(1/7— <br /> Title: f <br /> DO NOT WRITE BELOW THIS LINE <br /> RENS Application Approval: <L 'L WjA.-, Date: ALIO-VI <br /> Expiration Date: /!51 /1:?2 Date Paid: / / / Cash or heck /Z�-SOS Received By: ` <br /> EHD 45-015/2112 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />