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. o� D <br /> a ` "'"`'-•� SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT DEC 2 3 2011 <br /> 600 East Main Street, Stockton, CA 95202-3029 ENVIRONMENT HEALTH <br /> (209) 468-3420 Fax: (209) 464-0138 Web: www,sjgov.org/ehd PERMIT/SERVICES <br /> q�1 0"' <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 /> 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 II'' tt �r <br /> Medical Office/Business Name: US Rw� k��os <br /> Medical Office/Business Address U? 6, AIrA01, Sht. <br /> L (,h 01 S91 <br /> - - <br /> City State Zip Code <br /> Contact Person: Y1M ILl Y I a S <br /> Phone Number: 1 f7 <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> City Stale Zip Code <br /> Permitted Treatment Facility Name: <br /> Pcrmitted Troatment Facility Adr•iracc; ao II _ _ ..-._ ._)V" --- <br /> City State Zip Code <br /> List all employee names and titlEs autltoriz d to transport the medical waste (Ifore than 3, attach info <br /> 1. Name: rylU ILI Uri Title: � X <br /> 2. Name: J 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 enerator's or health care professional's facility. <br /> Applicant Signature: Date: <br /> I2� o(Il <br /> Title: r <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS I it Application Approval: Date: f5j/ <br /> te: <br /> Expiration Dat b\ At Date Paid: Iti 1 Z,491Cash orhec #: y� y�i� Received By: <br /> EHD 45-0111129111 APPLICATION FOR A WITEn QUANTITY HAULING EXEMPTION <br />