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i <br /> • SAN JOAQUIN COUNTY • lr, i`y , <br /> ENVIRONMENTAL HEALTH DEPARTMENT 1 <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:wvvw.sjgov.org/ehd ��t' 3 2006 <br /> <<a SAN J0�7dviN <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTI19ANORONMEN <br /> LTAL' <br /> TH DERAR-WENT <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management Act",the following <br /> conditions must be met: <br /> The generator or health care professional generates less than 20 pounds of medical waste per week,transport less <br /> than 20 pounds of medical waste at any one time,maintains a tracking document pursuant to Chapter 6 and the <br /> generator or parent organization has on file one of the following: <br /> 1. Medical Waste Management Plan if the generator or parent organization is a large quantity generator <br /> or a small quantity generator required to register pursuant to Chapter 4. <br /> 2. Information Document if the generator or parent organization is a small quantity generator not required <br /> to register pursuant to Chapter 4. <br /> Please complete the information below and mail with$72.00 fee 10 <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program O <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 <br /> Medical Waste Hauler InforfXALn <br /> ❑New KRenewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: <br /> Clh' State Zip Code <br /> Contact Person: )X t t& a Pett <br /> Phone Number: 7,;F J�/ <br /> Storage Facility Name: ' <br /> Storage Facility Address: o <br /> City State Zip Code <br /> .Permitted Treatment Facility Name: 0 ��Z — <br /> Permitted Treatment Facility Address: <br /> 74174 7177 <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste(If ore than 3, attach info): <br /> I. Name: Title: <br /> 2. Name: ` Title: <br /> 3. Name: Title: <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical waste records shall be kept on file at generator's or health care professional's facility. <br /> Applicant ignature: Date: <br /> Title: <br /> DO N T W I E BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: //5 /� <br /> Expiration Date: 17/ -3/ /_CL-?..7Date aid: o / *j /D(o Gosh 6F Check#: (p Received By: G <br /> EHD 45-01 <br /> 07/31/06 <br />