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SAN JOAQUIN COUNTY <br /> MX ENVIRONMENTAL HEALTH DEPARTMENT <br /> 44 <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <br /> �1F0•�� <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 healthcare 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. fie_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 /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Medical Waste Hauler Information <br /> ❑ New enewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address <br /> City State 'Zicode <br /> Contact Person: <br /> Phone Number: <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> City State Zip Code <br /> ---Permitted-Tmatrnent Facility.Name: <br /> Permitted Treatment Facility Address: — -- -- _ <br /> City State Zip Code <br /> List all employee names and titles authoriz d ttra part the medical waste (If rpore than 3, attach: info): <br /> 1. Name: Title: — _-- <br /> 2. Name: 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 generator's or he Ith re rofessional's facility. <br /> Applicant Signature: Date: <br /> Title: ` <br /> DO NOT WRITE; BELOW THIS LINE <br /> RENS Application Approval: Date: <br /> Expiration Date: 1 1 Date Paid: j 1 3 1 3 Cash or Check#: 21Y Received By: <br /> EHD 45.01 512112 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />