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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT DEC 2' 3 2011 <br /> t 600 East Main Street, Stockton, CA 95202-3029 <br /> i Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ENVIRONMENT HEREIN <br /> PERMIT/SERVICES <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,transport 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 <br /> or a 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 <br /> to register pursuant to Chapter 4. <br /> Please complete the information below and mail with$77.00 fee to: r 7 <br /> San Joaquin County Environmental Health Department <br /> ,x <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ❑New 'Renewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: <br /> q r52,9 <br /> State Zip Code <br /> Contact Person: t <br /> Phone Number: <br /> Storage Facility Name: _� a�vUJ "IDD�1`C►' t ���-' <br /> Storage Facility Address: U t <br /> lll 2l <br /> City State Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: I 3 t <br /> 60n kjarldkn 6A qV'5:7=�- <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste(If more than 3,attach info): <br /> �- Title: �S �-�P6 <br /> 1.Name: <br /> 2. Name: Title: 00Y5 401 <br /> 3. Name: Title: <br /> A copy of this exem ' an a cument shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical waste II be kept on file at generator's or health care professional' facil' <br /> Applicant Signature: — <br /> D te: <br /> Title Z *sus ) <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: (JI/ <br /> Expiration Date: Date Paid: Cash or heck# Received By: <br /> EHD 4S-01 <br /> 11/19/08 <br />