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UJ SAN JOAQUIN COUNTY ~ � ENVIRONMENTAL HEALTH DEPARTMENT •',� 1868 East Hazelton Avenue,Stockton,CA 95205-6232 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. Please complete the information below and mail with$77.00 fee to: San Joaquin County Environmental Health Department APPROVED Medical Waste Management Program o2 1868 E. Hazelton Avenue, Stockton, CA 95205-6232 Medical Waste Hauler Information ❑ New Renewal Medical Office/Business Name: P EO-N f AVl0W 6q M Ep(CA(..- GROUP Medical Office/Business Address: 1121 W V IN E ST 16 lop( CA 9540 City State Zip Code Contact Person: J EN N I F CI- 15EJ7- Phone Number: 20- 333- 'Wis Storage Facility Name: ADVAwM0 1 mm4 ug., CasN'fer- Storage Facility Address: 1031 S• ENIAMONT AVV_ Lop t CA 9S240 City State Zip Code Permitted Treatment Facility Name: 5'fep l<_1r-L-C MENAL \06S'[E Permitted Treatment Facility Address: 1-399 Ol' 0LATCLC OR C SAW LEP&DRO ca 9451*7 City State Zip Code List all employee names and titles authorized to transport the medical waste(If more than 3,attach info): 1.Name: JENN AFAR Qom.ISE.I- Title: MR.► IV-CAA- 2.Name: *Tkq-A SQV9-60 V Title: t.-ARL TF- 44- 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 ste records shall b kept on file at generator's or health care professional's >facilit / �+2 Applicant Signature— Date: Title: DO NOT WRITE BELOW THIS LINE R.E.H.S. Application Approval: — Date: 6L Expiration Date: / / Date Paid: /c)-/AU /f nZ Cash or heck Received By: EHD 45-01 11/19/08