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�» OPP SAN JOAQUIN COUNTYP>�ENVIRONMENTAL HEALTH DEPARTMENT304 East Weber Avenue,3dFloor, Stockton,CA 95202-2708 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd 1=c(, APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIO1 N JQF\QJlN QQEJNTyENVIRONMENTAL 9IEALTH DEPAR,M NT To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management Act",the 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 quantity generator not required to register pursuant to Chapter 4. Please complete the information below and mail with$72.00 fee to: San Joaquin County Environmental Health Department Medical Waste Management Program 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 Medical Waste Hauler Information ❑New enewal Medical Office/Business Name: ST IDS+, Medical Office/Business Address: __(_�0 a t-30?-TK GA-L-(F0 P-/11/11ti i- ST-0 C*-Tv rt C/A 6t.S9--04 City State Zip Code Contact Person: Phone Number: 2 D 11 A(p a- 10 4.11 Storage Facility Name: ST • `PSt2p W-5 W f�� ICA-t- C iJ i� Storage Facility Address: 1 A-0 t 0 F4-tf -,A-UF j9QJl& G{�t` CA City State Zip Code .Permitted Treatment Facility Name: _�1- ICA-L- Permitted Treatment Facility Address: 1c&b N 09TIA CA14--o EtJ(A- Sy 2 S-P Cly Tj aS City State Zip Code List all employee names and titles authorized to transport the medical waste(If more than 3,attach info): 1.Name: Sal✓ &-fl4e WCK)T Title: 2. Name: Title: 3. Name: 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 rec ds shall bekept on file at generator's or health care professional's facility. Applicant Signature: Date: 1 (o Title: MAt2MOV DO N T WRITE BELOW THIS LINE R.E.H.S.Application Approval: Date: IZ/ / Expiration Date: 11 / 31 /Date Paid: 12- l l S/U(a Cash o heck :*aY8 X39 Received By: EHD 45-01 07/31M