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PAY <br />ME <br />SAN JOAQUIN COUNTY RECE'VEp <br />EC 1 <br />ENVIRONMENTAL HEALTH DEPARTMENT D <br />.. . 2011 <br />.. 600 East Main Street, Stockton, CA 95202-3029 <br />(209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd .. . ENS ROA4 COUNTY <br />HEALTH MENTAL <br />'APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION vEPARTMENT <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, 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 the 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 FILE` i, <br />Medical Waste Management Program <br />- — - - --- <br />____ -a am ree � oc ton�A952C2=3a2,9---- - - <br />Medical Waste Hauler Information <br />❑ New Renewal <br />Medical Office/Business Name: <br />Medical Office/Business Address <br />Contact Person: <br />Phone Number: <br />Storage Facility Name: <br />Storage Facility Address: <br />Permitted Treatment Facility Name: <br />Permitted Treatment f=acility Address: <br />List all employee namgs and tif� a tre sport the medical waste (If more than 3, attach info): <br />1. Name: �-2 R t, Title: <br />2. Name: Title: <br />3. Name: Title: <br />A copy of this exemption and a tracking ocument aha b In employee's possession at all times while transporting medical waste. In addition, all copies of <br />medical waste records shall be kept o t gene r or hoalth care professional's faciltty. <br />Applic=SignaturQ7, Date:Title: <br />DO NOT WRITE BELOW THIS LINE <br />REHS Application Approval: Date: 1 <br />Expiration Date: jj/lbL Date Paid: / -241 � I / I Cash or Check #: /6490 Received By: V <br />EHD 45-0111129111 APPLICATION FOR A IMrEO QUANTITY HAULING EXEMPTION <br />