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SAN JOAQUIN COUNTY . G y MENT ENVIRONMENTAL HEALTH DEPARTMENT RECEIVED 304 East Weber Avenue,P Floor,Stockton,CA 95202-2708 �. �P• (209)468-3420•Fax:(209)468-3433 • Web:www.co.san joaquin.ca.us/ehd DEC 2 9 2003 tri=oRN APPLICATION FOR A LIMITED QUANTITY HAULING EXEMIRgW40UIN COUNTY ENVIRONMENTAL HEALTH 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,transport 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$70.00 fee to: San Joaquin County Environmental Health Department Medical Waste Management Program 304 East Weber Avenue, 3`d Floor, Stockton,CA 95202 Medical Waste Hauler Information ❑ New ® Renewal Medical Office/Business Name: Lawrence Livermore National Laboratory — Site 300 Medical Office/Business Address: Corral Hollow Road Tracy CA 95376 City State Zip Code Contact Person: Earl Thomas Phone Number: (925) 423-9676 Storage Facility Name: Browning Ferris Industries ( ri y_rlp) Storage Facility Address: 90 North 1100 West • North Salt Lake City Utah 84054 (See attached for additional stor%e facility) State Zip Code Permitted Treatment Facility Name: Browning Ferris Industries (Steri cycl P) Permitted Treatment Facility Address: 90 North 1100 West North Salt Lake City TTrah ging:ii City State Zip Code List all employee names and titles authorized to transport the medical waste(If more than 3,attach info): 1.Name: Joe Salazar Title: Hazardous WaGte MqnqgPmPnt Tech 2.Name: Don Dearing Title: Hazardous Waste Management Tech 3.Name: Joe Stonich Title: Hazardous Waste Management Tech A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In addition,all copies of medical waste records shall be kept le at ge torts or health care professional's facility. Applicant Signature: C. Susi Jackson Date: 1Z• Int Title: Division Leader, Operations & Regulato4 Affairs Division DO NO WTRI . BELOW THIS LINE R.E.H.S. Application Approval: Date: /$// Expiration Date:7/,3/ /�Date Paid: /�� Cash o eck Received By: EHD 45-02.001 10n/2003