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SAN JOAQUIN COUNTY pAY�E r�. { ENVIRONMENTAL HEALTH DEPARTMENT i �ECENEp ' 1868 East Hazelton Avenue, Stockton, CA 95205-6232 DEC 23 �n (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd .►0,4 `v�3 H6tL� Mf�MY APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION ' avr 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 $77.00 fee to: San Joaquin County Environmental Health Department APPROVED Medical Waste Management Program J ,, 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Medical Waste Hauler Information ❑ New Renewal Medical Office/Business Name: .45traCeVot IC Medical Office/Business Address 2A W- V� v tk L 0t 80-7 State Zip Code Contact Person: V1 mClS ` t( ► �S Phone Number: ALM ' ' 'L — 3,-9141 Storage Facility Name: ► W It, v7-756 ` Storage Facility Address: yo-haw f11/4 City t State Zip Code Permitted Treatment Facility Name: J cA Permitted Treatment Facility Address: "7 `*1- City State Zip Code List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): 1. Name: Ott 1-,Lt f' Title: &W 2. Name:1my, t A Title: K r 3. Name: �1' nA 6ayi 2,aA. ,-L- Title: PIN 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 gerLt on file ener oris or health care professional's facility. Applicant Signature: Date: irk �8 Title: Ni t F DO NOT WRITE BELOW THIS LINE REHS Application Approval: 9 Q A iL L c.�— Date: //71/, Expiration Date: 17- /3 1 /1 Date Paid: /L/ 23/ 3 Cash or ec : �51 f4-22-,y,Received By:1j� EHD 45-015012 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION