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)�PQU!M''cp SAN JOAQUIN COUNTY p c D <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 MAR 8 2012 <br /> (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehONVIRONMENT HEALTH <br /> oq<<F0f?z PEHMIT/SERVICE <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION 3 <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 pursuani 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 Information <br /> 0 New /Renewal <br /> Medical Office/Business Name: Ml-, <br /> Medical Office/Business Address p Prr G-PL <br /> ��1 1 C"p- <br /> City State Zip Code <br /> Contact Person: , A__� <br /> Phone Number: <br /> Storage Facility Name: <br /> Storage Facility Address: d�l,aer q S3a-G <br /> CityState Zip Code <br /> Permitted Treatment Facility Name: _d�f,,,, ir I P <br /> Permitted Treatment Facility Address: - �. <br /> �S cj <br /> City State Zip Code <br /> List all employee naRes and titles authorized to transport the medical waste (If more than 3, attach info): <br /> 1. Name: 'C�S�tlf l�) Title: R�aio, e_ <br /> 2. Name: Title: <br /> 3. Name: Title: <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 b pt on file at generator's <br /> or health care pr f`es\sional's facility. <br /> Applicant Signature: �iC,Yr v Date: <br /> Title: t,Y*ck- (j l+✓ . <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: ►.I�,.,`.�:` ,._. Date: s /j <br /> Expiration Date: t,11 Date Paid: `a / Al,Cash or Check#: Received By: <br /> EHD 45-0111/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION <br />