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0 <br />® PAYME <br />SAN JOA UIN COUNTY RECEIV,", <br />ENVIRONMENTAL HEALTH DEPARTMENT <br /><< f, 600 East Main Street, Stockton, CA 95202-3029 DEC 2 6, 2008 <br />{, Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd SAN JOAOUIN COUNTY <br />a ENVIRONM PCIU <br />NI <br />APPLICATION FOR A LIMITED QUANTITY HAULING EXEM �DEPARrM NT, <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 nit 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 <br />600 East Main Street, Stockton, CA 95202-3029 <br />Medical Waste Hauler Information <br />F1 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 />/A City _ _ State "Lip 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: e Qie-,0 Title: _ 7eA - L + 6Je l loaSS Direr <br />2. Name: e, n a tLka Title: C --V °tri r <br />3. Name: Title: " S4 <br />C-00 reQam, <br />A copy of this exemption and a track' document shall be in employee's possession at all times while transporting medical waste. In <br />addition, all copies of medical wast�reirds sha1J. t'e kept on file at generator's or health care professional's facility. <br />pplicant Signature: <br />;Title: � US' <br />Date: /.2 - / ,) - C r <br />DO NOT WRITE, JBELOW THIS LINE <br />R.E.H.S. Application Approval: Date: 1 / Z( /-05Expiration Date: 1 Z / 3L/ f� Date Pai / 2°1 / 08 Cash or Check #: S6% 1 2 Received By: T-6—_ <br />EHD 45-01 <br />11/19/08 <br />