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t <br /> c ,u . ,•. SAN JOAQUIN COUNTY 1 Er7 <br /> s...e.a ..-Q <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1500 East Main Street,Stockton. CA 915202-3029 <br /> (209)-163-3420 Fax: (209) 464-013B Web:www.sjgov.org/ehd JAN 14 2013 <br /> �F APPLICATION POR A LIMITED QUANTiTY HAULING EX.EMPTIOENVIRONMENTAL <br /> HEALTH DEPARTMENT <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 b-acking document pursuant to Chapter B 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. lnformatlon Docurnenf if the generator or parent organization is a small quantity generator not required to <br /> register pursuant to Chapter 4. <br /> Pleasa complete the Information below and mail with$77.00 fee to: <br /> PAYMENT <br /> San Joaquin County Environmental Health Department AW <br /> RECEIVED <br /> Medical Waste Management Program <br /> 6'00 East Main $treat, Stockton, CA 05202-3029 JAN 3 0 1013 <br /> Medical Waste Hauler InforrrIatIon "EM►�'iRONiiOaiT <br /> HEA118 DEPARTMENT' <br /> 0 New CRenewal <br /> ical Office/Business Name: . <br /> k4,�dicai Office/Business Address X W Lavise <br /> rti <br /> city State Zip Code <br /> Contact Person: C V&X1 .-- <br /> Phone <br /> Phone Number- 'tea- a^ <br /> Storage Facility Name: dlr U - x u; <br /> Storage Facility Address: k tA, QA <br /> city State Zip Code <br /> Perrnifted Treatment Facility Name: & <br /> Permitted Treatment Facility Address; _L VL$ ZJ <br /> V rent <br /> City State Zip Code <br /> List all employee names and Cities authorized to transport the medical waste(If more than 3,attach info), <br /> 1. Name; 52 `s�1r�+. a ti✓+_ Title: OR miiN s4exg-LU.0 <br /> 2. Name: .R� la.� e oad� Title: 2g, { <br /> 3. Name: TYX ZU ra Title: ,s` ZAMnn n&,.MR_ <br /> A Dory 4f this exampfion and a tracking doourmntshall be in employee's possession at all times whiiv transporting modiaal waste. In sdditlon,all copl*&of <br /> I>7odical woste retards shall be kept on file at gohor0 ar's or health we profeealonal's faGllIty. <br /> Appficani Signature; "-- `--� D2te.. <br /> Title. 9 — - <br /> DO NOT WRITE BELOW THIS LINT; <br /> iS Application Approval: -� Date: &3(11 <br /> Expiration Date: Date laid;�3�� t3 Cash o .Gh �AO�Received By: <br /> Ehia as of ytzaN t APPLICATION FOR A iMITEO quANTITY HAULING rzmw-now <br />