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f AN 09`''gl" c • SAN JOAQUIN COUNTY • a` ENVIRONMENTAL HEALTH DEPARTMENT .. 600 East Main Street, Stockton, CA 95202-3029 JAN 2:3 2012 (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd cq•.- .��P ENVIRONMENT HEALTH APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION PERMIT/SERVICES 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: Li FILE C San Joaquin County Environmental Health Department Medical Waste Management Program 600 East Main Street, Stockton, CA 95202-3029 Medlcal Waste Hauler Information ❑ New X Renewal 1� Medical Office/Business Name: RehctbFb_-US Medical Office/Business Address IS03 E. Mo;fci) Layle- Sul-k— N s cv_jrovx CA City State Zip Code Contact Person: &1r i essin tr Phone Number: ZO`'l "-i2_ S Storage Facility Name: Rf-MIOT-ocus -hwY ftof ,,Inc , - -dam +OXJS ft(!01 I`+h Storage Facility Address: 15b3 6 N101YC1n ca -C i ui-v— P% g-iuck o", Ct gSZ10 City State Zip Code Permitted Treatment Facility Name: ":W 1(c de , Permitted Treatment Facility Adaress q 135 W , S W 142 A- f CI<X k_, -Fresy-10 CPQ 013 22- City State Zip Code List all employee names and titles authorized to transport the medical waste (If more than 3, attach info): 1. Name: cyii ached 11St Title: 2. Name: Title: 3. Name: Title: 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 �_ 'A0 Date: I I Z-01 216 1 Z_ Title: frcAM n�s7Wafi Vc_ sSiSlzn4�k DO NOT WRITE BELOW THIS LINE REHS Application Approval '+l&-- Date: l&1//A/Aa, Expiration Date: 17"/ 91/ IZ Date Paid: /272/ `Z Cash or heck Received By: EHD 45-01 11/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION