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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> SFO <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <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 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 or a <br /> 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 to <br /> 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 APPROVED <br /> Medical Waste Management Program <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Medical Waste Hauler Information <br /> 0 New Renewal <br /> Medical Office/Business Name: Qan j0 CLCA\,u X-) Cc, C4A tc�Q 0--b <br /> Medical Office/Business Address \-)r 19,57-0 Lo <br /> Ci ty state Zip Code <br /> ,I;wx tear n, i e-(-Aq)f O� Czr,--�g -kin Py qrps <br /> Contact Person: <br /> Phone Number: q LACI U0 <br /> Storage Facility Name: ";n 1 r) LQ- C-� �&U L <br /> Storage Facility Address: =_1D-3—:Xf <br /> City C�- Ln� Zip Code Lp <br /> State CA <br /> Permitted Treatment Facility Name: Snax-IoS LO in�2U (I f)( 2-1 \nC, <br /> Permitted Treatment Facility Address: C1 7,—1,C ' � k 4 :2 <br /> WM, /kSA-ThD _j - L4 — __1_1 <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste(if more than 3, attach info): <br /> 1. Name: \Do f)nCa '?)e_LV_0nGln, UNA Title: ,� f)\A1 <br /> 2. Name: Vn:bL fig Title: "ZrV-\J O\ <br /> 3. Name: 0 - Title: <br /> 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 <br /> medical waste records shall 7bpt on file at goner4tor's or health care professional's facility. <br /> Applicant Signature: Date: <br /> Title: No(c*v <br /> DO NOT WRITE BELOW THIS,LINE <br /> REHS Application Approval: d Date: 17.1j:1-113- <br /> Expiration Date: i I'll 14 Date Paid: I -Cash or Check* Received By: <br /> EHD 45-015/2112 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />