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SAN JOAQUIN COUNTY 1- NT <br /> —N 3 <br /> EN *NMENTAL HEALTH DEP T=_�� <br /> It . Copy <br /> 600 East Main Street, Stockton, CA 952 2 ,, <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> EC 0 b 2010 <br /> SAN JOAOUIN COUNTY <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIOXNVIRONMENTAL <br /> HEALTH DEPARTMENT <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 dRenewal <br /> Medical Office/Business Name: yS We-I Na's <br /> Medical Office/Business Address: 20400 065! C-VATIO(n iX1V'>; , 301tE IUB <br /> A-::C "1pV\f t1 M n 000ee <br /> City State Zip Code <br /> Contact Person: SSAt 1 <br /> Phone Number: '3 di c ZCo Com <br /> Storage Facility Name: HO&Le, VaAr ly WIN �&w aaA00\, tOUk3N <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: SkA -PSR1 <br /> Permitted Treatment Facility Address: 9 2, 0,0 1 VE, n 0 1 I <br /> .14o(-)'sj 7-rvs� <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: fie I VQ-D1�C@ Q� Title: W6A(0Z=-, <br /> 2. Name: R MwC7 Title: _660-l tv 1C.lkN <br /> 3. Name: 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 medicalwaster"sh,1111kept onfile at generator's or health care professional's facility. <br /> Applicant Signature'\ kLj Date: 12-— Z —Z0 I C� <br /> Title: i-i t -2A' L6— <br /> DO <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: � -Q 1x_ Date: tV /VD <br /> Expiration Date: Date Paid: �' / Check#: \\ 3q2— Received By: ZG:`- <br /> EHD 45-01 <br />