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°' - oG SAN JOAQUIN COUNTY ENVWNMENTAL HEALTH DEPARTMer 60 ast Main Street, Stockton, CA 95202-3029 \c a Telephone: (209)468-3420 Fax: (209)468-3433 Web: www.sjgov.org/e ILE 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: PAYMENT San Joaquin County Environmental Health Department RECEIVED Medical Waste Management Program DEC 16 2010 600 East Main Street, Stockton, CA 95202-3029 "AN JOAQUIN couNn ENVIRONMENTAL Medical Waste Hauler Information HEALTHDEPARTLIENT ❑ New /Renewal Medical Office/Business Name: ��6-r/&& r 14fq 1 rSCAV1, ,- 5ne• Medical Office/Business Address: d(d ", PEASHW6 AUE• s U l tl A -7 City State Zip Code Contact Person: &W-11A a em Phone Number: -T!�vS — 075e Storage Facility Name: Pl s�-r C=SCAtiu& i4� &wIces , —T-n C- Storage Facility Address: pA44 1 i( ` AVo5:-, gut IE�- A 8-/-061<MAf &A- 9F a?-0t City State Zip Code Permitted Treatment Facility Name: IDA e:--r r ME AL Permitted Treatment Facility Address: . Q & 77D -1 ��6,C- u.lARAD, G • 9 ?4 City I State Zip Code List all employee names and titles authorized to transport the medical waste (If more than 3, attach info): 1. Name: G;Wa Dl ZOAJ . 12AJ Title: 011ZC-e;1-01e- OF ALIUM 1416 2. Name: Ti4CALOACi o Title: A&T 1%eiFC=7V& OF AUGIIII &117 3. Name: IA-/tLlT 1,V 1? A&/-V"/4-0P AAJ Title: RCCAAcSA-61&&9 A1111" A copy of this exemption anjacking document shall be in employee's possession at all times while transporting medical waste. In addition,all copies of medice records shall be kept on file at generator's or health care professional's facility. Applicant S ature: �� ✓tt Date: Title: ;��LIIC'i,t: ° DO NOT WRITE BELOW THIS LINE R.E.H.S. Application Approval: Date: -I K/ Expiration Date: / /�Date Paid: /,Z Cash orheck#I t. {o Received By: EHD 45-01