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QL,I"� • SAN JOAQUIN COUNTY • <br /> ENVIRONMENTAL HEAL RT JAN 13 2012 <br /> Q: <br /> 600 East Main Street, Stockt 02 ENV1HONMENT HEALTH <br /> .i . <br /> (209) 468-3420 Fax: (209) 464-013 e . 91 w.sjgov.org/ehd PERiMIT/SEHVICE3 <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 /> resister pursuant to Chapter 4. <br /> Please complete the information below and mail with $77.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ❑ New .Renewal <br /> Medical Office/Business Name: <br /> ()T�l n!G <br /> Medical Office/Business Address 1 <br /> D 4413) <br /> city State Zip Code <br /> Contact Person: kt1/1 N — E <br /> Phone Number: 2-j t, 6 5510 (�10 <br /> Storage Facility Name: MA I L. '9ACJe,- D�^A <br /> Storage Facility Address: MIA <br /> City I State Zip Code <br /> Permitted Treatment Facility Name: AR -S -h1 iAe F <br /> m1"5- <br /> Permitted Treatment 17261ity Address: 1 _ (� �—t1[.Y <br /> City State Zip Code <br /> List all employee names an titles authorized to transport the medical waste (If more than 3, attach Info): <br /> -- <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 b ept on fillg rator's or health care professional's facility. <br /> IC Applicant Signat19vDate: <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: SQ Date: Oi /,7/1'2. <br /> Expiration Date: 161- Date Paid: / Z1/ I Cash orheck : Received By: wVy� <br /> EHD 45-01 11/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION <br />