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SAN JOAQUIN COUNTY E ONMENTAL HEALTH DEPART T PAYMENT I - 60o East Main Street, Stockton, CA 95202-30 9 RECEIVED Telephone: (209)468-3420 Fax: (209)468-3433 Web: wwNv.sjgov.org/ehd FEB 14 2011 APPLICATION FOR A LIMITE UANTITY HAULING EXEMPTI0I� ENVIIRONMENTAL HEALTH DEPARTMENT 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, 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. Information Document if the generator or parent organization is a small quantity generator not required to register pursuant to Chapter 4. Please complete the inform tflon below --nd ni-A! with $77.00 fee te: RECEIVED San Joaquin County Environmental Health Department i�A 1 Z�j Medical Waste Management Program 600 East Main Street, Stockton, CA 95202-3029 ENVIRONMENTAL HEALTH Medical Waste Hauler Information PERMIT/SERVICES New enewal Medical Office/Business Name: (2- 49 _ Medical Office/Business Address: z 10 City `�- < State Zip Code Contact Person: _ -- Phone Number: 4-12- _�00'� Storage Facility Name: (AZ "Kl- -I eic- Storage Facility Address: t `�� - � `� -i- 4 —__ C^ gX21Q City State Zip Code Permitted Treatment Facility Name: ` e-L-e 'r-w'r Permitted Treatment Facility Address: 3 .5L_-, 44 A U-t_- Fr-C LA q :?;?7"Z City State Zip Code List all employee names and titles authorized to transport the medical waste (If more than 3, attach info): '- l. Name. ��- ^' - 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 medics records shall be kept on file at generator's or health care professional's facility. App Vc t Si- ure: Date: Title: DO NOT WRITE BELOW THIS LINE R.E.H.S. Application Approval: Date: Expiration Date:_17_� 'S1 / 10 Date Paid: of /\ Eash-vr Check#:jam Received By: Z_ EHD 45-0]