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iPqu 1 ry 0o SAN JOAQUIN COUNTY PAYMENT ' EONMENTAL HEALTH DEP E I& C E I VE D � :� 304 East Weber Avenue, 3rd Floor, Stockton,C 9 -2 ` ,; EYP• Telephone:(209)468-3420 Fax:(209)468-3433 Web: v EC 10 2004 Q�rFOR�` APPLICATION FOR A LIMITED QUANTITY HAULING EXEMP-AAQUIN COUY INTRONMENTAL 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 information below and mail with $70.00 fee to: San Joaquin County Environmental Health Department Medical Waste Management Program 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 Medical Waste Hauler Information ❑ New Renewal Medical Office/Business Name: lZe.44W-0"'r-vS �Ke Medical Office/Business Address: /3 ,k)- /",-u-4006 /2 <-Te i9,tK Com•• City State Zip Code Contact Person: DR'd4'0o�S.g- �'�ds�',c,�T . Phone Number: �20,9 ) y7 a- 2ro,s- Storage Facility Name: (11e�Qc� X11 t ��1p�edi� l Inc. Storage Facility Address: toes+42,rh Ale', crrrcu^Le CA ciO50t City State Zip Code Permitted Treatment Facility Name: (�40 w,eekz cak To C . Permitted Treatment Facility Address: -)a"7 k S • Wes-F-ervi Ave . i csrra.vi c CA City State Zip Code List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): 1. Name: S e:.e o,4o- lAe-d [1&f 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 ke t on file at generator's or health care professional's facility. Applicant Signatur Date: �- Title: DO NO WRI E ELOW THIS LINE R.E.H.S. Application Approval: hg, Date: L2j_Z,;' Expiration Date: �2 /J?/ /Date Paid: /�/ Cash or eck _� Received By: EHD 45-02-001 10/7/2003