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SAN JOAQUIN COUNTY c EN ONMENTAL HEALTH DEPARTNhNT y 304 East Weber Avenue,P Floor, Stockton,CA 95202-270 {209)468-3420•Fax:{209)468-3433 • Web:www.co.san joaquin.ca.us V 4{�pQRt� APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION 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 Iess 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. Please complete the information below and mail with$70.00 fee to: pp�YN1ENT RECE1vED San Joaquin County Environmental Health Department Medical Waste Management Program 304 East Weber Avenue, P Floor, Stockton,CA 95202 .lA� Medical Waste Hauler Information SANIOA�SON MEtUIN °p,LTM NF�LTH SEP R�M�� ❑ New Renewal Medical Office/Business Name: Medical Office/Business Address: 721 Calaverklis Lodi CA 95240 City State Zip Code Contact Person: Phone Number: 209.1 9-44 -4760 Storage Facility Name: 1,,100 U R t n a E W E D I r b 1 GRQU p t W M r Storage Facility Address: • Lodi CA 95242 -2185 City State Zip Code Permitted Treatment Facility Name: Permitted:Treatment Facility Address: 11875 White Rock Road Rancho Cordova , CA 95742 City State Zip Code List all employee names and titles authorized to transport the medical waste (If more than 3,attach info): 1.Name: _ _�.t e h Title: . 2.Name: flanPttP Suarez Title: lyse Prartinnar 3.Name: 01 i v i a F r 61id e Title: L .V .N . A copy of this exemption and a tracking document shall be in employee's possession at an times while transporting medical waste. In addition,all copies of medical waste reco s shall be kept on file at generator's or health care professional's facility. Applicant Signature: Date: Title: R -1-1- DO NOT WRI E BELOW THIS LINE R.E.H.S. Application Approval: Date: / Expiration Date: l_5 fl Date Paid: l l Cash o Check#: L�D n Received By: EHD 45-02.001 !0/7/2003