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SAN JOAQUIN COUNTY AYME TT ?� ENVIRONMENTAL HEALTH DEPARTMENT RECEIVED 1868 East Hazelton Avenue, Stockton, CA 95205-6232 NOV 2 7 2013 (209)468-3420 Fax: (209) 464-0138 Web:www.sjgov.org/ehd <iFOR SAN JOAQUIN COUNTY ENVIRONMENTAL APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION 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, transports 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 k9lMedical Waste Management Program L 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Medical Waste Hauler Information ❑ New Renewal Medical Office/Business Name: �7 [ G"' �'' � �9 ` eAvl as, 'rnc" Medical Office/Business Address AV F, f-�E A - I s;o ck TDAJ CA • qL 10 City State Zip Code Contact Person: I�lC��VA �'Q� Phone Number: v t59 6)1---F @ e, Storage Facility Name: W kA 9W/fi S' Wiwf -70C Storage Facility Address: :9"—'"-J A/, F69SINAIGAVG, SC11 ` City 67-OCIcro/.) State CA Zip Code (� � Permitted Treatment Facility Name: 54 V ETT MEPIC4L S J V/CES Permitted Treatment Facility Address: City State Zio Code List all employee narpes and titles authorized to transport the medical waste(If more than 3, attach info): 1. Name: r 5441L 11 Ulei4,RA1ttTitle: bi/RECTDR 2. Name: +066 ttilA /YI1R Title: RA-1 G�rSE A�'A/i/AfiC/Z 3. Name: MA, CP-lsriAJA /3ELCA/ &L) Title: /2/L/ C,4,SC- A4,4/IIAiCjgg 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 kep o file at generator's or health care professional's facility. J Applicant Si ure: Date: Title: �xlfill S'. v DO NOT WRITE BELOW THIS LINE REHS Application Approval: n d 1'� L.lm= Date: II/jam /13 Expiration Date:_JL, /l1 / f Date Paid:/I/2-7/ /3 Cash or Check#: 42,�o Received By: EHD 45-015/2/12 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION