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i t 03/23/2005 11 :23 FAX 209 963 6293 ST. JOSEPHS MEDICAL 1a 0031006 •` M__a` SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 East Weber Avenue, 3''d Floor, Stockton,CA 95202-2708 Telephone.(209)468-3420 Fax:(209)468-3433 Wzb.www.sjgov.org/thd APPLICATION FOR A LIMITED QUANTITY MAULING 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 less 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: I 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$70.00 fee to; San Joaquin County Environmental Health Department Medical Waste Management Program 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 Medical Waste Hauler Information E]New ❑ Renewal Medical Office/Business Name: jor T-0 " &r&r (, aaw Medical Office/Business Address: Maae—erfef City State Zip Cede Contact Person: �. Phone Number: hu4-i 7- G`f 71 Storage Facility Name: f90j CA, 6d46-U Storage Facility Address: t ou A, �` ray IF, City State Zip Code Permitted Treatment Facility Name: TO du Ij Permitted Treatment Facility Address; City State Zip Code List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): 1.Name: ik"di r►'�&-f1 Title: 2. Name; Title: 3.Name: Title: A copy of this exemption and a tracking document shall be in employee's possession at ate times while transporting medical waste. In addition,all copies of medical waste regio shall kept on llie at generator's or health care professional's facility. � / Applicant Signature: � Date: � 2 31� Title: c c� �v, ✓ r DON T WRI BELOW THIS LINE R.E.H.S. Application Approval: Date: 1�l — Expiration Date: /2-/ 31 / D Date Paid- L/ZO / S Cash or Check#: Z003 Received By EFD 45-02-001 WN2O05.