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A t1 t! <br /> 1 '_1 ENVIRO NTAL EPAR NTECEIVED <br /> •� <br /> ' 600 East Main Street,Stockton,CA 95202-3029 <br /> 1x ,� Telephone.(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.orglehd MAR 0 � 2010 <br /> APPLICATION FOR A LIMITED U TITY HAULING E _ •DENT HEALTH{ <br /> `T/SERdE <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management Act",the foll�o'wg <br /> conditions:must I----nizt; <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 hason 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 Informa,tion <br /> New ❑Renewal <br /> MedicalOffice/Business Name: v i O N(, <br /> Medical Office/Business Address: -3&01 _' <br /> V �- Orl ` <br /> City State Zip Code <br /> Contact Person: `2a <br /> Phone Number: <br /> Storage Facility Name: eoF ntr-,` '� <br /> Storage Facility Address: 7 ` n <br /> City State Zip Code <br /> Permitted Treatment Facility Name: U <br /> Permitted Treatment Facility Address: 't i '� <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: illi Title: <br /> 2.Name: 4 Title: MMAVVAt� <br /> '. <br /> 3.Name: t/Oh— �" ' Title: r® _ <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 wqste r cor s shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: ) j �- Date: !� <br /> Title: 2 tit V <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S.Application Approval: Date: <br /> Expiration Date:1_/ /` Date Paid: S / / f 0 Cash<r Check# ` Received By: <br /> EHD 45-01 '�. g� (D <br /> 11/19/08 <br />