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PRuHN'c SAN JOAQUIN COUNTY <br /> Q'_.r� . ENVIRONMENTAL HEALTH DEPARTMENT <br /> y� { <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> (209)468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br /> �lFOR <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: <br /> � <br /> San Joaquin County Environmental Health Department APPROVEZ <br /> Medical Waste Management Program <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Medical Waste Hauler Information <br /> ❑ New XRenewal <br /> Medical Office/Business Name: 12I t S <br /> Medical Office/Business Address S ;r, <br /> Cts � <br /> City state Zip Code <br /> Contact Person: " Y <br /> Phone Number: Z'A- 46(0-fdt5"S <br /> Storage Facility Name: 3 <br /> Storage Facility Address: 9-sa <br /> city State Zip Code <br /> Permitted Treatment Facility Name: ST 'GC4L't_*—= <br /> Permitted Treatment Facility Address: 3S I <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: `1 C`-ti�ro�tAE:� Title: u. S1S iT <br /> 2. Name: WM Title: <br /> 3. Name: ELY Title: <br /> A copy of this exemption and a tra docum t sh II be in employee's possession at all times while transporting medical waste. In addition,a!I cop!esof <br /> medical waste records shall be k t o fie at ge era is or health care professional's facility. <br /> Applicant Signature: C015NK_ T�?-y Date: <br /> Title: <br /> DO NOT WRITE BELOW THUS LINE <br /> REHS Application Approval:�2.n� U �Q -y Date: i7_�51 /J_'Z-- <br /> Expiration Date:11 f I.5 Date Paid. j 10- Cash or heck ,�)I Received By: <br /> EHD 45-01 5012 APPLICATION FOR A LIMITED QFJANTITY HAULING EXEMPTION <br />