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F � <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/chd <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,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;o�nnO <br /> VEA <br /> San Joaquin County Environmental Health Department t1Yi It <br /> Medical Waste Management Program <br /> 1868 E. Hazelton Avenue, Stockton, CA 95205-6232 '' <br /> Medical Waste Hauler Information <br /> ❑ New Renewal r r <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: <br /> City State Zip Code <br /> Contact Person: m d fly <br /> Phone Number: 9 UT-WIL <br /> Storage Facility Name: c-S . ,T <br /> Storage Facility Address: 1��l� C6W-01 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: S� �1TS 41i.j Cen <br /> Permitted Treatment Facility Address: * 0. <br /> T� <br /> n1 A- 5 <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: Title: <br /> 2. Name: Title: <br /> 3.Name: Title: <br /> A copy of this exemption and a tracking document shal a in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical waste record hall he ton file at generator's or health care professional's facil. Y. <br /> Applicant Signat re: —'J Date: <br /> Title: ear t 8 iced <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: 4. � ��,�_ Date: _j?I7)1/'-Li— <br /> Expiration <br /> '-Li .Expiration Date: Date Paid: I;1-I,WII d— Cash o Chec :/ 5062- Received By: <br /> EHD 45.01 <br /> 11/19/08 <br />