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u 1�,`� SAN JOAQUIN COUNTY `f ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton,CA 95205-6232 h '��:.•• � �,%f Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION 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. PA{ Please complete the information below and mail with $77.00 fee to: R ' V"T San Joaquin County Environmental Health Department AppROV SAN �AR 0 2Q D Medical Waste Management Program dOq 13 1868 E. Hazelton Avenue, Stockton, CA 95205-6232 r HE,q�H o/IV ou Medical Waste Hauler Information e�pgrMtNT New ❑ Renewal �c ov z r D4 Medical Office/Business Name: l" O C 0 S FR'd 5371.,o- Medical Office/Business Address: 115-03 ' A 6T bo A-&C H- SrOC K7160 CA r 916-0-1110 City StateZip Code Q , Contact Person: 04WDDC eT/� l� 4 e C,0 �;09- b{ reefol Phone Number: Storage Facility Name: I o �A-S 'r" A-&C Z—CL n @ Storage Facility Address: $ 't-0C, 14-?1 1-D CA 5� City State Zip Code Permitted Treatment Facility Name: ! Permitted Treatment Facility Address: ( . 5wi City State Zip Code List all employee names and titles authorized to transport the medical waste (If more than 3, attach info): 1. Name: ED A-) Title: CXCV6 U 1F-/Ll� l�✓`�� 1� 2. Name: ,S&,a d c?w1Title: —C4.0 e9-4)4&eA � Old 3. Name: i'YI ^ CAL r75 Kc��.� C� jtJIitle:1 � � R. 0 CAfes, A copy of this exemption and a track' g cumen hall be in employee's possession at all times while transporting medical waste. In addition,. copies of medical w t r co 1 shat b kept on fi4 L41- r% generator's or health care professional's facility. Applicant S nature: ✓�`� Date: Title: ) r DO NOT WRITE BELOW THIS LINE R.E.H.S. Application Approval: Date: :�'/5 f-3 Expiration Date: Date Paid: 3 / / 13 Cash o Check Received By: EH D 45-01 11/19/OR