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i� v _ P_WMW SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 cA�/FOR��P (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd 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: PAYit+iENT San Joaquin County Environmental Health Department APPROVE - RECciVED Medical Waste Management Program �E� 2 1868 East Hazelton Avenue, Stockton, CA 95205-6232 2013 SAN JOAQUIN COUNTY Medical Waste Hauler Information HECALTH WRO ETfANY ❑ New Renewal Medical Office/Business Name: �jQE� E'_\r9i'1J�:1"G1 •'J Medical Office/Business Address ] mond- 3 �o c�� CJS C15 2�i o City State Zip Code Contact Person: (ice C�SIe (. lnca.rr e,_ vvi•,A- Phone Number: 22�_)�-1.-- (�21 o-- 1,X7'2, Storage Facility Name: 0Cx.l1 1�11�St Storage Facility Address: „ C A c{,5 City State Zip Code Permitted Treatment Facility Name: CLI L Permitted Treatment Facility Address: 13 q5— Le__ r r Zen Lt->— I CA- Qt-16- 7M7 City -I State Zip Code List all employee na es and titles authorized to transport the medical waste (if more than 3IVY') ttach info): 1. Name: 1C � m , Title: t'1�9,i. -A 2. Name: �,r�n,b r1 �r1 ntX'S Title: r�r1_� t IM St% 3. Name: Title: A copy of this exemption and a rackIfile, doc ment shall be in employee's possession at all times while transporting edical aste. In addition,all copies of medical waste records shall be ept erator's ealth are professional's facility. 1 �� Applicant Signature: Date: l Title: It k IN DO NOT WRITE BELOW THIS LINE REHS Application Approval: Date: (2/ is/�S Expiration Date: /-/ Date Paid: /X1 2 / 13 Cash or Check#: 3 3'�7 Received By: EHD 45-015/2112 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION