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c _ <br /> SAN JOAQUIN COUNTY <br /> y ENVIRONMENTAL HEALTH DEPARTMENT <br /> �: � s'"''•'` 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> (209)468-3420 Fax: (209)464-013$Web: www.sjgov.org/ehd <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 AP �0 v <br /> Medical Waste Management Program <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Medical Waste Hauler Information <br /> 1-1 New LyRenewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address (f2 <br /> Cak q S20 -� <br /> City State Zip Code <br /> Contact Person: <br /> Phone Number: lM1(\l e— LZ0°1 - -7-7 l0 <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: f Yli G G(e- <br /> Permitted Treatment Facility Address: 0 11 tMe <br /> VL <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical wase(if more than 3, attach info): <br /> 1. Name: GVWI 114 C I Ve- Title: K-tty <br /> 2. Name: k vvtl 2 I0 1 r Fm Title: G �,, <br /> 3. Name: Gl <br /> LA X-C, _ Title: 2 V YVI SJ`Y" <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 be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: bate: ji! �� i.� <br /> Title: Ulreti7lyGl <br /> I <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval:, Date: / /s1 11-;� <br /> Expiration Date: 1.3 Date Paid: f Cash o Check 03 Received By: f� <br /> EHD 45-01 512/12 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />