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SAN JOAQUIN COUNTY ILE C wE �y ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street,Stockton,CA 95202-3029 cqc/ wl a`P. Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd oR 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 wi it$77.00 fee to: San Joaquin County Environmental Health Department F r `i y Medical Waste Management Program YMENT 600 East Main Street, Stockton,CA 95202-3029EIVED Medical Waste Hauler Information SEP 23 2009 9 New ❑ Renewal SAN JOAQl1iNEWRCOUNTY HFA►-IN DEPARTMNME ENT Medical Office/Business Name: rrVV keca USO-"P—a4N Se_.�V�Ce S 0011 sl O Medical Office/Business Address: a a.-1 l VWeS\- LqU kse Ave D� „nn,r,�2co. (-,A 9533-1 �P0d SSy1 City State Zip Code wp3 Contact Person: C�ac-o\cY.4e T^'0Q0de-Ck..Lk, YhNS�V 11P- 12A p�� Phone Number: 20g- $58-0188 Storage Facility Name: M n -Acaza VSt- "Za-1t n Se V\kc&S Storage Facility Address: UJ2Sk- 1-0\1) e Ave nLQC%-kesA O A q 5331 City State Zip Code Permitted Treatment Facility Name: i Cum Permitted Treatment Facility Address: VALasnlh _ Coot- City 4City State Zip Code ��—/ List all employee names and titles authorized to transport the medical waste(If more than 3,attach info): 1. Name: Coco\ire 'Wn%bOdQrMk Title: tireCAOC O� 2.Name: Pm%Ao, Y\o3^V-AS Title: Y\v t-S e 3. Name: PeA k.rueae-r Title: Sc.� \l�t�S2 ok Y 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 kept on file at generator's or health care professional's facility. Applicant Signature: ` ° / Pl Date: at' cl - 01 Title: t\�ceg kr)c OF N4�!aIAV, S�c-V�ce5 DO NOT WRITE BELOW THIS LINE R.E.H.S. Application Approval: � Date: M /IZ-/0?— Expiration Date: / /�Date Paid: /13, /6 Cash o Check#•—I/kg�ND Received By: EHD 45-01 11/19/08