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Ul SAN JOAQUIN COUNTYRO� iQ z E RONMENTAL HEALTH DEPAR NT 304 Ea Weber Avenue, 3`a Floor, Stockton, CA 95__2-2708 /c (% (209) 468-3420 ■ Fax: (209) 468-3433 - Web: www.co.san-joaquimcams/ FB Q G" �P �^/ APPLICATION FOR A LIMITED QUANTITY HAULING EXE�'V Rei/ q(T//,,,, To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Act" ,g'following conditions must be met: The generator or health care professional generates less than 20 pounds of medical waste per week, transport less than 20 pounds of medical waste at any one time, maintains a tracking document pursuant to Chapter 6 and the generator or parent organization has on file one of the following: 1. Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a small quantity generator required to register pursuant to Chapter 4. 2. Information Document if the generator or parent organization is a small quan ' en for not required to register pursuant to Chapter 4. Please complete the information below and mail with $70.00 fee to: San Joaquin County Environmental Health Department Medical Waste Management Program 304 East Weber Avenue, 3`d Floor, Stockton, CA 95202 Medical Waste Hauler,Information ❑ New p Renewal Medical Office/Business Name: SAN JOAQUIN COUNTY HEALTH CARE SERVICES DEPARTMENT Medical Office/Business Address: P.O. Box 1499 / 500 WEST HOSPTTAT, ROATI French Camp, CA 95231 City State Zip Code Contact Person: Chuck Peek Phone Number: (209) 468-6166 Storage Facility Name: ::N Storage Facility Address: City State Zip Code Permitted Treatment Facility Name: San Joaquin General Hospital Permitted Treatment Facility Address: 500 West Hospital Road French Camp, CA 95231 - City State Zip Code List all employee names and titles authorized to transport the medical waste (If more than 3, attach info): 1. Name: Max Cervantes Title: Housekeeping Service Wnrker 2. Name: Jose Lopez Title: n if it 3. Name: Luis Huante Title: A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In addition, all copies of medical waste recor s shall be kept on file at generator's or health care professional's facility. Applicant Signature: )& Date: i Title: Fari 1 i ti eg Mansour DO N T WR TE BELOW THIS LINE R.E.H.S. Application Approval: Date: ,7/fes/ Expiration Date: /Z /,51 / vDate Paid: Z //b Cash or Check #: Received By: EHD 45-02.001 10/7/2003