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r?/ ,-1T SAN JOAQUIN COUNTY 1 ` ; ' ��I I't l' 1 ENVIRONMENTAL HEALTH DEPARTMENTt , t li sAt,! 10AQUiN C01 i 600 East Main Street, Stockton, CA 95202-3029 ENVIRo ;ErITt )N� Ttv5EN7 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov 9 ; 0 .� 1,r1` tI i APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIO?� To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management Op conditions must be met: The generator or health care professional generates less than 20 pounds of medical waste per week,transport 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. ,may Please complete the information below and mail with$77.00 fee to: �!U� PAYMENT RECEIVED San Joaquin County Environmental Health Department _ Medical Waste Management Program F)9 d DaD`v a� SEP 0 3 2010 600 East Main Street, Stockton,CA 95202-3029 kB p 34?71 r SAN JOAQUIN COUNTY Medical Waste Hauler Information ENVIRONMENTAL_ HEALTH DEPARTMENT New D Renewal Medical Office/Business Name: �,A 1 t J 4ec l W C1,`1e-5 s 4,40 r) Medical Office/Business Address: _ i l 361 IV: FIVyn OVI T -33r,(,C=T _ City State Zip Code Contact Person: L G' )etc.,. .�-- Phone Number: aC1 i Y 514 L-P - -_1 , F) �( ' i �4(;..-7 Storage Facility Name: US Storage Facility Address: 1`f GA ''/'J vy)cr� C. P+ cel C/=3 City State Zip Code Permitted Treatment Facility Name: >+f?-4-j (!{ Permitted Treatment Facility Address: l "i - 4�K2,10 X13722 City State Zip Code List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): 1.Name: � `,.1) rr.d Title: VD,l\l l(,`lb')Si i[: Ob o�-b 2.Name: Title: 3.Name: Title: 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 Taste records shall be kept on file at generator's or health care professional's facility. � Applica Signature: Cil,u-,4- x �� Date: ;C) 0 Title: �tL.�� DO NOT WRITE BELOW THIS LINE R.E.H.S. Application Approval: Vim.. Date: Expiration Date: / / !a Date Paid:q/ _Z /�CasChec :��Received By: EAD 45-01 11/l9/08