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SAN JOAQUIN COUNTY <br /> y EI*ONMENTAL HEALTH DEPART&T <br /> 600 East Main Street, Stockton, CA 95202-3029 FILE C <br /> P 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. <br /> Please complete the information below and mail with$72.00 fee to: <br /> San Joaquin County Environmental Health Department PAYMENT <br /> Medical Waste Management Program F(-Fn <br /> 600 East Main Street, Stockton, CA 95202-3029 NOV 2 <br /> 7 20G1 <br /> Medical Waste Hauler Information 3ANJOAQUINCOUNTy <br /> ENVIRONMENTAL <br /> Q New A Renewal HEALTH DEPARTMENT <br /> Medical Office/Business Name: 06 P�tYI Y <br /> Medical Office/Business Address: --ICO C=wt�tY on, <br /> U 5 2-Z K2 <br /> ty , State Zip Code <br /> Contact Person: iS LLQ <br /> Phone Number: <br /> Storage Facility Name: O U 1 oa- Ul - <br /> Storage Facility Address: <br /> City __ State Zip Code <br /> � <br /> Permitted Treatment Facility Name: f-2Xl de, <br /> Permitted Treatment Facility Address: !0 W ' <br /> l,Ucncl > <br /> City State Zip Code <br /> List all employee names/ d titles authorized to transport the medical waste(If more than 3, attach info <br /> 1. Name: n, Title: <br /> 2. Name: -n Q o r?or 5610, Title: 9yle& <br /> 3. Name: Title: <br /> A copy of this exemption and a tracking cument shall be in employee's possession at all times while transporting m dical waste. In <br /> addition,all copies of medical w to rec s sh l ept on file a aerator's or health care professional's cility. r <br /> Applicant Signature: Date: << "( <br /> Title: <br /> DO NOT WRIT BELOW THIS LINE <br /> R.E.H.S. Application Approval Date: /IZ/- <br /> Expiration Date: 17,/51 / Date Paid: i t Check#: , Received By: _ <br /> EHD 45-01 <br /> 10/02/07 <br />