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Au N <br /> SAN JOA UIN COUNTY <br /> j E ONMENTAL HEALTH DEPAR� � :�- E M VEDD <br /> 91. 600 East Main Street, Stockton, CA 95202-3029 _ `—'� <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/e�i,:" <br /> 16 2008 <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPT HEALTH <br /> MITISENCES <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$77.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ❑ New CeRenewal <br /> Medical Office/Business Name: 4--�gt el <br /> Medical Office/Business Address: <br /> C L*tv State Zip Code <br /> Contact Person: le <br /> Phone Number: —7 <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> Cultv State Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): <br /> 1. Name: Title: <br /> 2. Name: Title: <br /> 3. Nam 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 Si ature: _ Date: <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: 6XI&L& <br /> Expiration Date: 12 / 771 / Date Paid: \ / o Ch k Received By: <br /> EHD 45-01 <br />