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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 Act", 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 following: 1- Medica/ 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 $67 FEE T0: San Joaquin County Public Health Services Environmental Health Division Medical Waste Management Program [� 304 E Weber Ave Stockton, CA 95202 Medical Waste Hauler Information 0 New G Renewal Medical Office/Business Name: Lawrence Livermore National Laboratory - Site 300 Medical Office/Business Address: Corral Hollow Road City: Tracy State: CA Zip Code: 95376 Contact Person: Stanley Terusaki Phone #: (925) 422-1539 Storage Facility Name: Browning Ferris Industries Storage Facility Address: 90 North 1100 West City: North Salt Lake City State: Utah Zip Code: 84054 (see attached for additional s orage aci ity.) Permitted Treatment Facility Name: Browning Ferris Industries 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 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 on file at generator's o health care professional's facility. Applicant Signature: C. Susi Jackson Title: Division Leader — Operations & Regulatory Affairs Division Date: -3 Do Not Write Below This Line R.E.H.S. Application Approval:phDate: 4/%(j/lql;Fxpiration Date: / Z/:5 EH4502 10-03-96 Date Paid 2/ / Cash or Check'? Z c;C'4 1-7'1�circle) Acct iGYl