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°Qu�N SAN JOAQUIN COUNTY PAYMENT ENVIRONMENTAL HEALTH DEPARTMENT RECEIVED e• .a N , 600 East Main Street, Stockton, CA 95202-3029 DEC $ Zp» (209)468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd SAN JOAQUIN COUNTY ENVIROMENTAL APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIbf*fLTH DEPARTMENT 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: FILE C San Joaquin County Environmental Health Department Medical Waste Management Program 600 East Main Street, Stockton, CA 95202-3029 Medical Waste Hauler Information New Renewal Medical Office/Business Name: ,E Medical Office/Business Address GI�Y` 3 City State Zip Code Contact Person: OS a, t'r'y. Phone Number: 20 q S ULO — 1211) 2 Storage Facility Name: 01 C,I V1<n Z cw, I'�-• Storage Facility Address: ILPIb 9c;,2—,4?— City k State Zip Code Permitted Treatment Facility Name: Y" Permitted Treatment Facility Address: Q__I_ ._ 1_ City State Zip Code List all employee nam andlitles a t rized to transport the medical wa to (f more t an 3, attach info): 1. Name: f(TAG Title: f 1,A. 2. Name: C'1 d' I Title: n 3. Name: Title: A copy of this exemption and tracks g document shall be in employee's possession at all times while transportin meds al waste. In addition,all copies of medical waste records shall kept file nerator s or Ith care professional's facility. , (- 71 I Applicant Signature: Date: Title: ` DO NOT WRITE BELOW THIS LINE REHS Application Approval: �t q Date: `tZ/I/d Expiration Date: `Z/ �� /kZ Date Paid: t Z/ U / Cash or heck :Z(Q-L Received By: _ EHD 45-0111129/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION