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Paui�� <br />/°°c SAN JOAQUIN COUNTY {{�� <br />(� y E ONMENTAL HEALTH DEPAR T <br />600 East Main Street Stockton CA 95202-3029 <br />c �P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov. 08 <br />APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTI � RO W HEAD <br />E MIT/SEMACE <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 <br />600 East Main Street, Stockton, CA 95202-3029 <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 />10-b 1111OW 6141 /iC, �6 SP/ 77 c / /,.-H k" IqE e`fC4-L% %f <br />�'LI lC_S IV!) 4 N Clt1 aJJ17 1 627-1t T/�'S <br />�96 S. Fi4/,U&/,j T- AUS'. <br />City State Zip Code <br />Permitted Treatment Facility Name: <br />Permitted Treatment Facility Address: <br />City State Zip Code <br />kALY maie G>p Looe <br />List all employee names and titles authorized to transport the medical waste (If more than 3, attach info): <br />- iii►; .'r <br />r - <br />3. Name: <br />Title: <br />Title: <br />Title: <br />A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In <br />addition, all copies of medical waste records shall be kept on file at generator's or health care professional's facility. <br />Applicant Signature: <br />Title: < �Ft-7 V <br />DO NOT WRITE BELOW THIS LINE <br />R.E.H.S. Application Approval: -L.- Date: ._/ <br />Expiration Date: j L / / Date Paid: V2— / 1 6 / ® Check9 Received By: YL_ <br />EHD 45-01 <br />