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PquI, Atz r'Oj..F ° �oG SAN JOAQUIN COUNTYi') ENVIRONMENTAL HEALTH DEPAR11 C 2010 600 East Main Street, Stockton, CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd SAN JOF 0UfN COUNTY cQ�iFOR'NP FNVir rONMENTAL APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIO�I�TH DFPARTrnENT 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,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. o l.) DDd OD q Please complete the information below and mail with$77.00 fee to: �-��-0 (o aO- 1 San Joaquin County Environmental Healih Department APL bb3 C 4 4E D Medical Waste Management Program P(1-t? 53s'7 q3 600 East Main Street, Stockton, CA 95202-3029 P� SSS Medical Waste Hauler Information New ❑ Renewal Medical Office/Business Name: r^ A U AJ e-!--,-Aw6X Medical Office/Business Address: Is � `u6ea1 rK AvfiA�-t-� Calow CA City State Zip Code Contact Person: w 1Y�l Phone Number: n( � `��> q G X 6- Storage Storage Facility Name: l �,{fnr �(�f,L�1�Li N bmjL- Storage Facility Address: l.ly,� S-Vlr Istru,t S Si ce — (61�� G4 �>ty State Zip Code Permitted Treatment Facility Name: ��-6G .0 Permitted Treatment Facility Address: R:j Zk (,0 nn* V_e5 _ AJ Cam Ae�eS CX 70 P.A_ City State Zip Code List all employee n es and titles authorized to transport the medical waste(If more than 3, attach info): 1.Name .R SS _ �'Yl(C �,t , • � Title: Tcl S, -,C-� �AAVI - 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 medi waste records shall be kept on file at generator's or health care professional's facility. Applica Signature s Date: 1 G od Title: h, { DO NOT WRITE BELOW THIS LINE R.E.H.S. Application Approval: Date: Expiration Date: 4X1Z/_SL/It—Date Paid:. \\ / \\o l kb E=4Fev Check#: Received By: EHD 45-01 11/19/08