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02a SAN JOAQUIN COUNTY <br /> ;J FILE ' <br /> EN�ONMENTAL HEALTH DEPARTAT <br /> T <br /> PY <br /> 600 East Main Street, Stockton CA 95202-3029 <br /> �,. 1 .� <br /> \ePi Telephone:(209)468-3420 Fax: (209)468-3433 Web: www.sjgov.org/ehd t r t D <br /> -..7� <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION ,„-,,- <br /> _J r <br /> To qualify for a "Limited Quantity Hauling Exemption"pursuant to the "Medical Waste Management Acf';`the-'-,theA , g <br /> conditions must be met: <br /> The generator or health care professional generates less than 20 pounds of medical waste per week, transport less <br /> than 20 pounds of medical waste at any one time,maintains a tracking document pursuant to Chapter 6 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 <br /> or a small quantity generator required to register pursuant to Chapter 4. <br /> 2. Information Document if the generator or parent organization is a small quantity generator not required <br /> to register pursuant to Chapter 4. <br /> Please complete the information below and mail with $77.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ❑ New Renewal <br /> Medical Office/Business Name: 0Ctc n c t , P cn,�-i`k� (�dj L"o-al h"' <br /> Medical Office/Business Address: -�'7 0-7 <br /> S tvo,K-fm U4- a 5 <br /> City State Zip Code <br /> Contact Person: <br /> Phone Number: V <br /> Storage Facility Name: Sq-i-) ,j Lctc�tui I,I N,,t,U-+Lt C+-f) Le of f'cht1-4-iinti_ <br /> Storage Facility Address: Imllswbr(d i)i' <br /> City State Zip Code <br /> Permitted Treatment Facility Name: � '- 'S env i i-ury)EnbL,(- 5eA-v i tom. <br /> Permitted Treatment Facility Address: ISLjq (VSE Luop <br /> EaA- az� 1 x <br /> City IjState Zip Code <br /> List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): <br /> 1. Name:--S VW- 1 0 0 url 1 Title: <br /> 2. Name: lo Title: NU'-sy- 0, )rd iraf-c r Tv�, <br /> 3. Name: Title: N1 t sc C- DoEAi rict+rr- <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical wto recors shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: Date: 1-2�1 1 1 0 <br /> Title: Ui r-e-C+cr LL- 01,0nor-e.-1 y- lye- f ad Oa r;fir al hS <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: 6 l/oSAO <br /> Expiration Date: t Z / / 10 Date Paid: ! / / 10 Cash or deck • 5 )9-S_7&L Received By: <br /> qRi— <br /> EHD 45-01 <br />