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SAN JOAQUIN COUNTYfallVILE C3 rv�',� qu <br /> , r <br /> a t_ IMONMENTAL HEALTH DEPAR NT ✓ <br /> JAIV <br /> 600 East Main Street, Stockton,CA 95202-3029 5 ZQ1�? <br /> Telephone;(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orgland SRrv,1p <br /> �`• •a AC?utN <br /> ��i oma ENvlF?orV COUNTY <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIONEiu-H vE AERrM�� <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. <br /> Please complete the information below and mail with$77.00 fee to: <br /> San Joaquin County Enviromnental 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: katrh S <br /> Medical Office/Business Address: 3vo3 iza5k 4 `-106 <br /> _ rN CA q 59L 15 <br /> City State Zip Code <br /> Contact Person: tA4al✓ G edal��r <br /> Phone Number: <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: <br /> Per-mr-itted Treatment FaCllity Address: <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: �"X e te, le"k!rd Title: e-k-) <br /> 2.Name: AcA,. _ D Y' Title: - <br /> 3. Narne: 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 waste records shall be kept on file at generator's or health care professional's facility. <br /> Applic t S}}�nature. Date: <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: p� C,-- Date: Z 1 24 Lc) <br /> Expiration Date: 114 / Zgl /IV Date Paid: 1 /of Cash orheck#' �� oL Received By: <br /> EHD 45-01 <br />