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� v <br /> r <br /> � RAMM SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT DEC 2 0 2011 <br /> •2 <br /> 0:; { 600 East Main Street, Stockton, CA 95202-3029 <br /> • �° '• <br /> • (209) 468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd ENVIRONMENT HEALTH <br /> •..-- --.•..�P PERMIT/SERVICES <br /> ��%FO•R� <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <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 <br /> Medical Waste Management Program <br /> 600 East Main Streettockto- CA95202-3029___ <br /> Medical Waste Hauler Information <br /> ❑ New ARenewalMedical Office/BusinesssName: 1'71-ey-tcu,, fYt-eL <br /> Medical Office/Business Address q0d S & -1; Q -K_ R' <br /> S sa*3 <br /> City State Zip Code <br /> Contact Person: al La Y­, <br /> Phone Number: -gfflb 99 3 - <br /> Storage Facility Name: -cam d Q 12 <br /> Storage Facility Address: -e ay-el- a 54yce E,_ ,-t ,S7u 3 <br /> ity ]] State Zip Code <br /> Permitted Treatment Facility Name: 4—e i <br /> Permitted Treatment Facility Address: _ <br /> l�e3 n(> +2 93 7)-)�— <br /> City State Zip Code <br /> List all employee n es and title +authorized �o tra>port the medical waste (If more than 3, attach info): <br /> 1. Name: C(1 �-t� >�d (,LS7 Title: <br /> 2. Name: Title: <br /> 3. Name: Title: <br /> A copy of this exemption and a tracking document shepll be in ployee's possession at all times while transporting medical waste. In addition,all copies of <br /> medical waste records shall be kept on file at er for's r alth care professional's facility. <br /> Applicao Signature: Date: <br /> Title: <br /> �- DO NOT WRITE BELOW THIS LINE <br /> REHS Application ApprovaL� , . Q_ �Ql�y Date: / <br /> Expiration Date: V Z/31 /12— Date Paid: (21/ U I �� Cash ore Alli`-�01 Received By: <br /> EHD 45-01 11/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION <br />