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SAN JOAQUIN COUNTY 1 E ONMENTAL HEALTH DEPART T 6� g 0 J+ _ 6 East Main Street, Stockton, CA 95202-3077 Telephone:(209)468-3420 Fax: (209)468-3433 Web: www.sjgov.org/ehd 1(-J o Y--- " L 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: San Joaquin County Environmental Health Department r, Medical Waste Management Program 600 East Main Street, Stockton, CA 95202-3029 DEC 16 2010 Medical Waste Hauler Information S.4N JOAQU,;NCUUNn EWRONMENTAL ❑ New Vj Renewal HEALTH°EPARTMENr Medical Office/Business Name: SaA UG U - 6k�l tQ- —ilb, CK Medical Office/Business Address: 3tY IV' City State "Lip Code Contact Person: 1 w Phone Number: C 1 Storage Facility Name: ,l Cl' , Q� fi Storage Facility Address: u CK-nYA C 9�5�D (,,City State Zip Code Permitted Treatment Facility Name: S t t�X S Permitted Treatment Facility Address: �" /� J r✓ City State Zip Code" List all employee names and titles authorized to transport the medical waste (If more than 3,attach info): 1. Name: f)I Co . "a V-�,j Title: G 2. Name: `h 141 0VV, Title: U-Q- 3. Name: Y S' i2(V Title: tiI,LS-P �,hll(_, J I'1� 71V A copy of this exemption and a tracking document shall be in employee's possession at all times ile transporting medical waste. In addition,all copies of medical waste records shall be kept on file at generator's or health care ofessionagl's facility. Applicant Signature: Date: -3�,b ' ' Title:Dye-C�hv, �{- (ii�gt7V'261� n.sld�f �i,l ��l Vn,( f1'LLr1 DO NOT WRITE BELOW THIS LINE R.E.H.S. Application Approval: � ��.�. _Date: Expiration Date: 1q1 ))Date Paid: /tel ll Q Cash or Check#: Received By: EM 45-0]