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SILti '°N WdS� l �IOZ '6 '3a4 ;W11 paAia°ad <br /> PAYMENT <br /> oEa�[ry, <br /> SAN JOAQUIN COUNTY RECEIVED <br /> D <br /> zENVIRONMENTAL HEALTH DEPARTMENT C <br /> �_.�..:._•:_ � 9 2013 <br /> ` 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Sate CoA <br /> ••cr•.-�-,.•� EfYVIRONMOUN y <br /> t uR`' (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd HEALJN DEPAR ENTAL <br /> WENT <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 APPROVED�' 1'�Tt, <br /> U_ <br /> Medical Waste Management Program �. <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Medical Waste Hauler Information <br /> 0 New ( Renewal <br /> Medical Office/Business Name: -� , at re C-12 te <br /> ' <br /> Medical Office/Business Address le,43 — , <br /> Inn <br /> City State Zip Code <br /> Contact Person: <br /> Phone Number. — 1010—"60 <br /> — <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> city State CGZ qi5a 19 Zip Code <br /> Permitted Treatment Facility Name: r I <br /> Permitted Treatment Facility Address: ` ;a.' ' ' <br /> City State `-' Zip Code <br /> List all employee names and tftLes authorized to transport the medics waste (If more than 3, attach info): <br /> 1. Name: .� tom- (A�T14G <br /> 2. Name: PSA on Title: R <br /> 3. Name: _PQr.-c,,r,. Ao Com PAZ 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 2�m <br /> yera�ttor's orr hhealth care professionaall'ss ffac�ili'ty.Applican Si nature: t1"ItG1r�l {/t"� V Date: <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: C'� -- Date: ib-&-L <br /> > <br /> Expiration Date: I/ 14Date Paid: 12- Cashyr6lteck�i'A. Received By: <br /> EHD 45-015012 Co <br /> # I tkAV APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> b/Z E LOZ-60-Z L w'd S L:1717:L0 LLL L <br />