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..,� SAN JOAQUIN COUNTY � E ONMENTAL HEALTH DEPART 1, >_ L E T-A 600 last Main Street, Stockton, CA 95202-3029 �° P• Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd 2010 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION+N.; :;yco uiw ENV;rioJ,M UNTy HEALTH-+J ENrA.I_ To qualify fora Limited Quantity Hauling Exemption�,pursuant to the Medical Waste Management Act", thiE� TQ* 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 $77.00 fee to: San Joaquin County Environmental Health Department Medical Waste Management Program 600 East Main Street, Stockton, CA 95202-3029 Medical Waste Hauler Information ❑ New p(Renewal Medical Office/Business Name: YY1D.nkcclx l l�sD-�eo��4h SP rV i t�S Medical Office/Business Address: 22711 Mgs* C.oWslr Ave CPO swans. ft!M CA 8533'1 City State Zip Code Contact Person: Co-C-0ktwC T)r`OmdeoaA Phone Number: 21041 • 8S$• cqg& Storage Facility Name: nnDun�=M uo tl- - kg--� Storage Facility Address: 2.2-1t buts }- LDuiSft Avg vvlew-.I�r_of CA 9S?-3`7 City State Zip Code Permitted Treatment Facility Name: S 1-Cr%r -fh, Permitted Treatment Facility Address: tA13S 0. SvkAJ�A- Q 4--S r\.0 CA 01 37111 City State Zip Code List all employee names and titles authorized to transport the medical waste (If more than 3,attach info): 1. Name: QP r0kthe 7% �Wgjtg t_ Title:biMtAor 0� ��SE�viCeS 2.Name:_ 'Pow.lO`__ T-\LK Qs, Title: SeVNMk V%Q Me, 3. Name: Pcq. {GruCAQf` Title: %Cj, o©i Y\VTSe 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 recordsshallbe kept on file at generator's or health care professional's facility. Applicant Signature: Date: Title: D1T'CG*or' Oq "e AMS S2niki .S DO NOT WRITE BELOW THIS LINE R.E.H.S. Application Approval: 4*,.,Com-- Date: X114-1 Expiration Date: Date Paid: Cask.ctr Check#: a 3 �p Received By: CfZ- EHD 45-0]