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SAN JOAQUIN COUNTY PAYMENT N { ENVIRONMENTAL HEALTH DEPARTMENT RECEIVED 304 East Weber Avenue,P Floor,Stockton,CA 95202-2708 (209)468-3420•Fax:(209)468-3433• Web:www.co.san-joaquin.ca.us/ehd DEC 2. 9200 3 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMIGPF499QUIN COUNTY ENVIRONMENTAL 1.MTH 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 I 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 City' State Zip Code Contact Person: Earl Thomas Phone Number: (925) 423-9676 Storage Facility Name: Browning Ferris Industries (Steri rvr 1 Pl Storage Facility Address: 90 North 1100 west North Salt Lake City Utah State Zip Code (See attached for additional stoQlV'e facility) Permitted Treatment Facility Name: Browning Ferris Industries (Steri cycl e) Permitted Treatment Facility Address: 90 North 1100 West North Salt Lake itv iTrah, 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 WAStP MA7lAgPTian 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 a at ge tor's or health care professional's facility. Applicant Signature: C. Susi Jackson Date: L Z' Title: Division Leader, 0 erations & Re ulato A Sion DO NO WRI E BELOW THIS LINE R.E.H.S. Application Approval: Date: I �A Expiration Date: �/.3� /�Date Paid: Cash o eck Received By: EHD 45-02-001 10/72003