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1k <br />0 <br />E <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.orglehd <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 $77.00fee. to ;IDRO <br />VE <br />San Joaquin County Environmental Health Department �Y, A <br />Medical Waste Management Program <br />1868 E. Hazelton Avenue, Stockton, CA 95205-6232 <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 Facility Address: <br />rct- Ctate 7.in Code <br />City State Zip Code <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: S,�k Title: <br />2. Name: Title: <br />3. Name: Title: <br />A copy of this exemption and a tracking document shat a in employee's possession at all times while transporting medical waste. In <br />addition, all copies of medical waste record "hall be t on file at generator's or health care professional's facil' y. <br />Applicant S, —J Date: <br />Title: bj''C. - 44. D. -Or W14 14"0-t- (.Benne' <br />DO NOT WRITE BELOW THIS LINE <br />R.E.H.S. Application Approval:Q---��,,�Q� <br />Expiration Date: I 7;o Date Paid: /;- 1.2d /ld-- Cash o Chec : I15 -002 - Received By: <br />EHD 45-01 <br />11/19/08 <br />