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�p<,y,�cE po • SAN JOAQUIN COUNTY D ENVIRONMENTAL HEALTH I T Q: a I < 600 East Main Street, Stockton, CA 5 2 29 JAN 18 2012 (209) 468-3420 Fax: (209) 464-0138 Web: www.sigov.org/ehd � .'-�`P ENVIRONMENT HEALTH _FOt% APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION PERMIT/SERVICES 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, transports 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. - (lij -_rl Please complete the information below and mail with $77.00 fee to: San Joaquin County Environmental Health Department Medical Waste Management Program 600 East Main Street, Stockton, CA 95202-3029 I Medical Waste Hauler Information U New I I Renewal //pp (� Medical Office/Business Name: &Vl TOM (1y1 l�tt�/1�/ U1JICf ocJ G�/, f&I^- Medical Office/Business Address 9707 -T-m y SLC5y U QrNe- sbx�-k a5 Q-®eo Cit State Zip Code Contact Person: Q� CDbu -o - roA�tc .n0-ft ^tom 441 �iM"15 _ Phone Number: �Nq_ ca 9—�f�q(do � L� � � n Storage Facility Name: 9*11�i9�QUI Yl &E[V C t77'P fki �Yu fa-- "o - StorageFacilityAddress: d-107,�f/f i�l't.�Sl�9or{d we City ✓` '{tl /� ' State Zip Code Permitted Treatment Facility Name: Permitteci Treatment Facility Address: �— O City State Zip cole List all employee names and titles authorized to transport the medical waste (If more than 3, attach info), Title: — I d 1 fZtWi$ 2. Name: ( C Title: AX SC 3. Name: e, Title: -Oyg2 j9, CAoq / .rr',,ce_ 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 k214 on file at generator's r health care professional's facility. Applicant Si nature: �l�`°� Date: 10 1 12- Title: ZTitle: DO NOT WRITE BELOW THIS LINE REHS Application Approval: Date: AL/ tj_/V Expiration Date: IZ /'�l /�Z- Date Paid: I / / 1L Cash or Check 0 $5�c1 Received By: � EHD 45-0111/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION