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- -r^oy4758356 ASERACARE 05W p.m. 01-24-2011 212 01/24/2011 16:28 20946.38 F LE 10 Cpv?Rl ENTAL HEALTH PAGE 01/01 SAN JOAQUIN UOUNTY a x� ENVIRONMENTAL HEALTH DEPARTMENT ` 600 East Main Street,Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www,s,igov.org/chd JAN 2 5 2011 APPLICATION FOR A LIMITED QUANTITY HAULING RXEMPT)Q,ky ;;;�.,- To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management Ab'e.,the l'ollo ing conditions must be met: The generator or health care professional generates less than 20 pounds of medical waste per week,transport 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. Injormatlon Document if the generator or parent organization is a small quantity generator not required to trgister pursuant to Chapter 4. Please complete the information below and mail with 577.04 fee to: San Joaquin County Environmental Health Department RE yMENT Medical Waste Management Program CEIVED 600 East Main Strect,Stockton,CA 95202.3029 JAN ? 2011 Medical Waste ,Hauler Inform atooin V-1QgQU/ O New j Renewal H .TM'Q�pMENn .,.. Nr Medical OfiicefBusiness Marne; S q G ek t2 }tis 1p t C Medical Office/Business Address}� �5 7 a w-CK C__H E City State Zip Code Contact Person: Phone Number: Storage Facility Name: 2- c q Storage Facility Address: City State Zip Code Permitted Treatment Facility Name: S14t,4 C.4 C,U, e— . Permitted Treatment Facility Address: c i ev o-{ Tit okQ 5 Rd a c M City State Zip Code M a u tt 1 .91 S HA4--r14 "o c-n .. List all employee names and titles authorized to transport the medical waste(If more than 3,attach info): 1.Name: M61-,H p(A L lo tt Cr Title: P-1 u c .1 - 2.Name: P6,e5ea41 U Title: " A e " 3.Name: G K"S -I--TO Title: _ !_o o q Q"-T&C T I L-4 c.t Q_ p c_ w" A copy Of this exemption and a tracking document shall be in employee's poS$cSsion at all times while transporting medical w2oe. In addition,all copies of medical waste records shall be kept an file at generator's or health care professional's facility. Applicant Signature: �Ob(t o ��r Z�Q, �(nl QCC Date: t 2 11 Title: nl Q C C_ �"� DO NOT WRITE BELOW THIS LINE R.E.H.S. Application Approval: pate: a* / Expiration Date:IL/ AI LLI—Date Paid: get+-ff Check Atli t Slo Received By: 11yr" EED 45.01