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oP Y SAN JOAQUIN COUNTY <br /> f j EAWNMENTAL HEALTH DEPART1W FILE COry <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web: www.sjgov.org/ehd <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, 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. PA _ <br /> Please complete the information below and mail with $77.00 fee to: <br /> p <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program `' <br /> 20,10 <br /> 600 East Main Street, Stockton,CA 95202-3029 SAN jC)AOUIN COUNTY <br /> ENViRON110ENTAL <br /> Medical Waste Hauler Information HEALTH DEPARTMENT <br /> ❑New 'Renewal <br /> Medical Office//Business Name: <br /> Medical Office/Business Address: Lf60 S. n �✓ n Lti e <br /> She1�� A 9s� 3 <br /> City ' State Zip Code <br /> Contact Person: el 6 01,441-f. cr 63d�l1 dzi <br /> Phone Number: - LO 9T ao �- 9 q349 V - <br /> Storage Facility Name: j'l'Z..z� P62t-r ' <br /> Storage Facility Address: yo o S 6ies d <br /> S �f� <br /> C---V <br /> City State Zip Code <br /> Permitted Treatment Facility Name: 4eVK t o)C- L c. <br /> Permitted Treatment Facility Address: s� f,J, <br /> csnv C4 <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste (If more than 3, attach info): <br /> 1. Name: a c�Tc-Q Lkl — Title: <br /> 2. Name- Title: - <br /> 3. Name: Title: <br /> A copy of this exemption and a tracking document shall be inemployee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical waste recor hall be pt o e at rator's or health care professional's facility. <br /> Applicant Signature: Date: <br /> Title: +r c� en•s +�ci r� <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Dn. ?cDate: <br /> Expiration Date: Date Paid: 2 3 l JD Cash o he #:/D4$3f Received By: <br /> EHD 45-01 <br />