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D it <br />AquN <br />SAN JOA IN COUNTY <br />y :� ENVIRONMENTAL HEALTH DEPARTMENT <br />-� 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />cq�P (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />�lsoR <br />e ► e : Ze1�1_lL1ltI1fig/my-All III III, Cc3 /=I1Ti121[01 1 <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 AP!:PR4OV� <br />Medical Waste Management Program <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Medical Waste Hauler Information <br />❑ New W4enewal <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 />%1 j I _ atd VV LIIJ %,uuu <br />City State Zip Code <br />List all employee n9aigs and title§,, authorized to transport the medical waste (If more than 3, att h info): <br />1. Name: e 6i tee?, Title: <br />2. Name: T -46-b et4 Title: ¢S' <br />3. Name: 1%uC.A N rt! 0 Title: <br />A copy of this exemption and a tracking document <br />medical waste records shall be kept on file at gene <br />Applicant Signature: <br />Title: 10W40.1L <br />be in employee's possession at all times while transporting medical waste. In addition, all copies of <br />s or health care professional's facility. <br />Date: <br />Aj S e $ U, CEJ <br />DO NOT WRITE BELOW THIS LINE <br />REHS Application Approval: I& C1 Date: iZ /ll_/L?— <br />Expiration Dater/51 /1 Date Paid: fol / / Cash o Chec • /676D7 Received By: _ <br />EHD 45-015/2112 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />