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■ <br /> SAN JOAQUIN COUNTY <br /> `= ENVIRONMENTAL HEALTH DEPARTMENT <br /> Ida t <br /> 1868 East Hazelton Avenue,Stockton,CA 95205-6232 <br /> (209)468-3420 Fax:(209)464-0138 Web: www.sigov.org/ehd <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 qua ntky 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 mall with$77.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program t]1 <br /> 1868 East Hazelton Avenue, Stockton,CA 95205-6232 <br /> Medical Waste Hauler Infarma#Ian <br /> ❑ New P(Renewai <br /> Medical Office/Business Name: Ul�J <br /> Medical Office/Business AddressE. pcyry <br /> . � <br /> ri <br /> city State zip Code <br /> Contact Person: 4 � ri- <br /> Phone Number: q <br /> Storage Facility Name: �? <br /> Storage Facility Address: <br /> City Slate Zip Code <br /> Permitted Treatment Facility Name; Lti <br /> Permitted Treatment Facility Address: r- <br /> Gl.. <br /> City state Zip Code <br /> List all employee names and tlties authorized to transport the medical waste(If more than 3, attach info): <br /> 1. Name:M1 Y-1 Of aS Title: h eY- <br /> 2. Name: n;as Yl Title: <br /> 3. Name: SNCQ6,Y1C eiC'_y-CA!E Title: <br /> A copy of this exemption and a tracking document shall be In employee's possession at all tunes while transporting medical waste. In addition,all copies of <br /> medical waste records shall be k ton file at generators or alth care professional's facility. <br /> Applicant Signaturg: Date: 'r1 2 <br /> Title: 1 t <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval.. pate: 0/1 (3 <br /> Expiration Date: I Zy ZA I Date Paid: I X 1171/Z Cash or Check#: 4 q-703'.?—Received By: <br /> EHO 45-01 5WI2 APPLICATION FOR A LIMITED QUANTITY HAULING ExEI IPTION <br />