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San Joaquin County Public Health Services Environmental Health Division Medical Waste Management Program APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Acts% 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 fallowing: 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 567 FEE TO: San Joaquin County Public Health Services Environmental Health Division Medical Waste Management Program 304 E Weber Ave Stockton, CA 95202 Medical Waste Hauler Information ❑ New U Renewal Medical Office/Business Name: Lawrence Livermore National T ahnratnry — Cita 3QO Medical Office/Business Address: Corral Hollow Road State: r.n Zip Code: 95 i7h City: Tracy Contact Person: Vicki Salvo Phone m:425/47'1-54.1? Storage Facility Name: Browning Ferris Industries (St_e_zi oyc._1_e) — Storage Facility Address: 90 North 1100 West — City: North Salt Lake City State: Utah _ a ac men or additional storage foci lite) Permitted T feat-nent Facility Name: Browning Ferris Industries XSterj.s _ Permitted Treatment Facility Address: 90 North 1100 West — City: North Salt Lake City ___State: _g>a _ List all employee names and titles authorized to transport the medical waste. If not 1- Name: Linda Garcia Tilde: RPgi GtPrPrl N11rCP 2- Name: Rob Tageson Title: H.,.,..rdolis WactP Mgmt Tonh 3- Name: Joe Stonich Title: Hazardous Waste Mamt. Tech A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. in addition, all copies of medical waste records shall be kept on His at gen s or heth care professional's facility. Applicant Signature: C. Susi Jackson C �y�. - Title. Division Leader/Operations & Regulatory Affai ra\Ili Date: Do Not Write Below This Line '' R.E.H.S. Application Approval: Date: 1' /,(0 /0 Expiration Date: EH4502 10-03-96 Date Paid 7i / Cash or Check s (circle? Acct /