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PAY%1E1,\i7- San Joaquin County Public Health Se Ices RECEIVED Environmental Health Division Medical Waste Management Program JAN 112002 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTSAN JUtiQUIN COUNTYt ,lfIEA�TH SERVICES a.,�._1:-ALTH 01ufc;:, To quality for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Act% the following conditions must be met: i he generator or health care professional generates less than 20 pounds of medical waste per week, transpoits less than 20 pounds of medical waste at any one time, maintains a tracdng document pursuant to Chapter 6, and the generator or parent organization has on Sle one of the following: I- 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 S67 FEE TO: ��EVE10 San Joaquin County Public Health Services JAN 112002 Environmental Health Division ENVIRONMENT HEALTH Medical Waste Management Program PERMIT/SERVICES 304 E Weber Ave Stockton, CA 95202 Medical Waste Hauler Information n New (2 Renewal Medical Office/Business Name: Lawrence Livermore National Laboratory - Site 300 Medical Office/Business Address: Corral Hollow Road State: CA Zip Code: 95376 City: Tracy Contact Person: Vicki Slavo Phone" 925-423-5432 Storage Facility Name: Browning -Ferris Industries (Stericvcle) Storage Facility Address: 90 North 1100West City: North Salt Lake City State: Utah Zp Code: 84054 SPP attar�hari fnr nddi ti nnal etnraaa fare 11 Yv_1 Permitted Treatment Facility Name: Browning Ferris Industries (Stericycle) Permitted Treatment Facility Address: 90 North 1100 West City: North Salt Lake City State: Utah Zip Code: 84054 List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. 1- Name: Linda Garcia Title: Registered Nurse 2- Name: Rob Tageson Title: Hazardous Waste Mgmt. Tech. 3- Name: Joe Stonich Title: Hazardous Waste Mgmt. 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 an file at generato�ealth re professional's facility. Applicant Signature: C. Susi Jackson Title: Divj5iQn Lpacier — Date: I / 7 /—01- Do Not Write Below This Line R.E.H.S. Application approval: Date: /U,/02Expiration Date:�7/ / Eii4502 10-03-96 Date Paid j / r/ / 02- Cash or Check S�S f 33 5 (circle) Acct