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San Joacuin County Public Health Services evironmental 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- 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 $67 FEE TO: San Joaquin County Public Health Services Environmental Health Division Medical Waste Management Program P.O. Box 388 Stockton, CA 95201-0388 Medical Waste Hauler Information :11 New 52 Renewal Medical Office/Business Name: Lawrence Livermore National Laboratory - Sir.?. 300 Medical Office/Business Address: Corral Hollow Road City: Tracy State: CA Zip Code: 95376 Contact Person: Stanley Terusaki Phone *- (510) 422-1539 Storage Facility Name: Integrated Environmental Systems Storage Facility Address: 499 High Street City:. Oakland - -1 State: CA Zip Code: 94601 — (See attached sheef for additional storage 75c7itv. Permitted Treatment Facility Name: Integrated Environmental Systems Permitted Treatment Facility Address: 499 High Street City: Oakland State: CA Zip Code: 94601 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 Taizeson rite: Hazardous Waste Management Tech. 3- Name: Joe Stonich Title: Hazardous Waste Management Tech. (See attached sheet for additional employee.) 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 or health care professional's facility. Applicant Signature.. C.Susi Jackson �- --- Title: Division Leader - Operations & Regulatory AffADivision _Date: 2 / 27 97 Do Not Write Below This Line R.E.H.S. Application Approval: 70,/2b, Date: 3//2/99-Expiiration Date: PH4302 10-03-96 Date Paid 1 3 4- Cash o�CC�h 20�� (circle) Accti��—