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u Y SAN JOAQUIN COUNTY <br /> EN VI&NMENTAL HEALTH DEPARTM <br /> 600 ast Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web: www.sjgov.org/ehd <br /> C/FSR <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 /> i <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. <br /> Please complete the information below and mail with $77.00 fee to: <br /> San Joaquin County Environmental Health Department R YcF/DEC 'v— <br /> Medical Waste Management Program �0 <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> '10A <br /> Medical Waste Hauler Information E�7RONugN <br /> ",cau <br /> HE41.T>♦p6 AR S <br /> ❑New lk Renewal <br /> Medical Office/Business Name: + 1 <br /> Medical Office/Business Address: <br /> ucrdl � 5 <br /> GtE, <br /> ' State Zip Code <br /> Contact Person: 0.'f <br /> Phone Number: o Le —( <br /> Storage Facility Name: � � pd.L ~�-�(A�1-1 t <br /> Storage Facility Address: 14 >1 <br /> I ml I - <br /> City State Zip Code <br /> Permitted Treatment Facility Name: eP'® 1--L1 - <br /> Permitted Treatment Facility Address: 1 000h <br /> City State Zip Code <br /> List all employee name and titles authorized to transport the medical waste (If more than 3,attach t fo): <br /> 1. Name: Title: l /` � G` C 1S <br /> 2. Name: Vit'i )0y^ f Title: 011.2 <br /> 3. Name: Title: <br /> A copy of this exemption an a tracking document shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medic I wap re- r shall be ke ,on file at generator's or health care professional's cility. <br /> r 1 0A <br /> Applicant Signature: ° Date: I ( 2 <br /> Title: <br /> DO OT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: / 1 <br /> Expiration Date: ' / j / I Date Paid: le—A-1 / / /0 Cash or Check#: Received By: <br /> EHD 45-01 <br />