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ECLIVED SAN JOAQUIN COUNTY IAN 2 0 2012 ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street Stockton CA 95202-3429 EN IFIONMENOALNlALTH Telephone:(209)469-3420 Fax:(209)468-3433 Web:www,$)gov.org/ehd PERM1T/Sl~RVICE, APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management Act",the following conditions must be met: The generator or health care professional generates less than 20 pounds of medical waste per week,transport fess than 20 pounds of medical waste at any one time,maintains a tracking document pursuant to Chapter 6 and the generator or parent organization has on file one of the following: 1. Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a small quantity generator required to register pursuant to Chapter 4. 2. Information Document if the generator or parent organization is a small quantity generator not required to register pursuant to Chapter 4. Please complete the information below and mail with $77.00 fee to: A� X2811 1 � San Joaquin County Environmental Health Department ��13 3 FILE -1VMedical Waste Management Program P _T�'_7 9 600 East Main Street, Stockton,CA 95202-3029 L{55( Medical Waste Mauler Information New ❑ Renewal Medical Office/Business Name: Pmn 'Cu >,r- Pik! l NAD _ Medical Office/Business Address: _� &galk __Ave ' i Ott' Tyac.XA CA 9,53-7 CQ City State Zip Code Contact Person: 1�o.SetnQ na �, efrr�? Phone Number: ZOci. lQ (o Storage Facility Name: ?f an)CLk V—u 01G-r QA" ► 4�- _._ Storage Facility Address: 1 rc fc kg_ o-tom- City State Zip Code Permitted Treatment Facility Name: ou ' n Cnu �orls. Fact Permitted Treatment Facility Address: 'JV60 , BETr qe 1 , Soh S�ockh�n{ C qG--�D`4 City State Zip Code List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): 1. Name:t?CCLtx RIJICA Title: KX_t 2. Name: _a5e_maA4v, e z. Title: 1 k, s 3. Name: Title: 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 medical waste records shall kept on fil at generator's or healthcare professional's facility. Applicant Signature: Date: (0 9- I Z Title: WV). DO NOT WRITE BELOW THIS LINE R.E.H.S. Application Approval)- Date: I I lTlr Expiration Date: l�/ ?74 / 7, Date Paid: D I L Z-Cash o Check 7,� Received By: EHD 45-01 11/19/08