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SAN JOAQUIN COUNTY <br /> '2 ENVIRONMENTAL HEALTH DEPARTMENT <br /> • 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> (209)468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br /> <<FOR <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <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, transports 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 or a <br /> 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 to <br /> register pursuant to Chapter 4. <br /> Please complete the information below and mail with $77.00 fee to: pAYilyE <br /> RECEIVED <br /> San Joaquin County Environmental Health Department <br /> AP <br /> p��V� NOV <br /> Medical Waste Management Program 9 7012 <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 ' `� H"ANJO NM�COU <br /> Medical Waste Hauler Information <br /> ' �cpeR� � <br /> ❑ New ❑ Renewal Pr <br /> Medical Office/Business Name: <br /> Medical Office/Business Address U/ ' <br /> City State Zip Code <br /> Contact Person: 0 �� ��� �� <br /> Phone Number: <br /> Storage Facility Name: <br /> Storage Facility Address: City S57CCk'M tate CA �/�ip ode <br /> Permitted Treatment Facility Name: k 412V)-6T7_ 6V-' t� > <br /> Permitted Treatment Facility Address: (ix -1 <br /> City State Z.,Code <br /> List all employee nags a!Q}d titles authorized to transport the medical wase (If more than 3, attach info): <br /> 1. Name: 104- i v -,ltd Title: l Or ,� UICASI Ei <br /> 2. Name: E < / /U' Title: <br /> 3. Name: Title: <br /> A copy of this exemption and a track ng document shall be in employee's possession at all times while transporting medical waste. In addition,all copies of <br /> medical waste records shall becl <br /> n file at generator's or health care professional's facility. <br /> Applicant Sign e: . Date: l` <br /> Title: t <br /> DO NOT WRITE BELOW THIS LINE <br /> REH.S Application Approval: ., Date: <br /> Expiration Date: / 4 ?) Date Paid: l l ��l l� Cash or Check#: 21 Received By: r—ll <br /> EHD 45-015/2/12 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />