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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 ca .. (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd ��F D APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION 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, transports 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 $77.00 fee to: PAYMENT ,�D RECEIVED San Joaquin County Environmental Health Department t].� PROV ,1 NOV Medical Waste Management Program 1 3 0 2012 1868 East Hazelton Avenue, Stockton, CA 95205-6232 S^" ,Ro,,a HEEL-rH 0ER EMTAL Medical Waste Hauler Information ❑ New 'renewal Medical Office/Business Name: Medical Office/Business Address City ��'` State Zip Code Contact Person: Kul e, 1!)Gi r r C-- Phone Number: '-U 11 J 3A-,-Lo t'2-0 2- Storage Facility Name: Storage Facility Address: City State Zip Code Permitted Treatment Facility Name: f 1 Permitted Treatment Facility Address: lialo - � r. ��n1�clro C`Acl z-l/i-7 -7 City State Zip Code List all employee name and titles authorized to transport the medical waste (If morean 3, attach info): 1. Name: ►�Ir� Title: t A- C 2. Name: nC 0 VVbY Title: 1- 3. Name: Title: A copy of this exemption and a tracking document shall be in employee's possession at all times while transportin medical Aaste. In addition,all copies of medical waste records shaI o a gene or's or health care professional's facility. ��T Applicant Signature: Date: (/ Title: n DO NO WRITE BELOW THIS LINE REHS Application Approval: l 2.��0, J 9n-- Date: L: /,j-/j_Z Expiration Date:-0--L?,J/ I :R Date Paid:�/02�/�Cash or Checker Lq 75 Received By: EHD 45-015/2/12 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION