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�n • R / �oP uI .co • SAN .�OAQUIN COUNTY � V� ENVIRONMENTAL HEALTH DEPARTMENT Budget 600 East Main Street, Stockton, CA 95202-3029 4 DEC 5 2011 •' & Ris►< (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd iso 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, 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. Please complete the information below and mail with $77.00 fee to: Fh5MM San Joaquin County Environmental Health Department JAN -6 2012 Medical Waste Management Program hnn Eac ton CA 95202-3029 ENVIRONMENT HEALTH _ PERMIT/SERVICE. Medical Waste Hauler Information - I ❑ New ❑ Renewal Medical Office/Business Name: NVT�F Medical Office/Business Address City State Zip Code Contact Person: 1L�iA-N C12 Phone Number: 2c9—47ClaL Storage Facility Name: t I C ' G Storage Facility Address: 1�;1 R' ' i`" IDE 29• City S'fuc-rTD N State CA Zip Code 9sLl) Permitted Treatment Facility Name: ST I CyG-t,r✓ Permitted Treatment Facility Address: Lt 135 Isr A-VE: �6yy Com-- 5 z IZZ City State Zip Code List all employee names and titles authorized to transport the medical waste (If more than 3, attach info): 1. Name: VC--I_N tc A Title: 11 2. Name: Iv1 r Title: 3. Name: \IV1 LL xA+A lei: L Title: IF2 tA_ 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 ke t on Ile at neratoes or health care professional's facility. Applicant Signature . w Date: J Ic I I" Title: 44 1 t DO NOT WRITE BELOW THIS LINE REHS Application Approval: Date: 44.1101/12.. Expiration Date: IZ/ 31 I IZ Date Paid: I / IP / I?- Cash o Check �J1 p $(kr) Received By: EHD 45-01 11/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION