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SAN JOAQUIN COUNTY <br /> EN�ZONMENTAL HEALTH DEPARTh1T <br /> � `• i 600 East Main Street, Stockton, CA 95202-3029 <br /> ` + <br /> Telephone: 209 468-3420 Fac: 209 468-3433 Web: www.s ov.or lehd <br /> p t ) ( } Jg g <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 to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program Ott <br /> 600 East Main Street, Stockton, CA 95202-3029 i Zd�Q <br /> F F <br /> Medical Waste Hauler Information SAN <br /> ❑ New Renewal <br /> nnnnyy t i�. . <br /> Medical Office/Business Name: a.TOW �S �_ CaQ, L��►► <br /> Medical Office/Business Address: lop a- She <br /> &U*RA CCS}- q'S <br /> City State Zip Code <br /> Contact Person: Mhvi I&W�& <br /> Phone Number: <br /> Storage Facility Name: 3t. h�, C <br /> Storage Facility Address: A <br /> City State Zip Code <br /> Permitted Treatment Facility Name: S <br /> Permitted Treatment Facility Address: 100 S <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: 4Pf 1�'�XY�Y1 Title.- <br /> 2. <br /> itle:2. Name: � Title: <br /> 3. Name: Title: <br /> A copy of this exemption and a tracking document shall be in ployee's possession at all times while transporting medical waste. In <br /> addition,all co"ofmedical waste rec all be kept o e at generator's or health care professional's faacility. <br /> Applicant SDate: IW �� �o <br /> Title: hreSV�f,�S <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: r * /7//0 <br /> Expiration Date: fl Date Paid: _jZ1_7l—LZ? Cash o �rc :�, �Received By: -- <br /> EHD 45-01 <br />