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olU1M SAN JOAQUIN COUNTY I " N i ONMENTAL HEALTH DEPAR'Ii� 10 CENED .`` 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209)468-3420 Fax:(209)468-3433 Web:www,sigov.org/ehd SEP 3 Q 2009 APPLICATION FOR A LIMITED QUANTIFItAELIlj yp IfVVI"*'ITHEALTH 11 1RL9MIT/SERViCES 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. Please complete the information below and mail with$77.00 fee to: San Joaquin County Envirortrnental Health Depart-ment Medical Waste Management Program 600 East Main Street, Stockton, CA 95202-3029 Medical Waste Hauler Information ❑ New '5�fRenewai llJJ Medical Office/Business Name: Medical Office/Business Address: /V, City 1 _ State Zip Code Contact Person: �c-vG-�7T ��, z• Phone Number: — Storage Facility Name: Storage Facility Address: City State Zip Code Permitted Treatment Facility Name: Permitted Treatment Facility Address: Y J'J— Citv State Zip Code List all employee names*d titles authorized to transport the medical waste(If more than 3, attach info): 1. Name: .f �� Title: s✓� r -. 2. Name: �- 3. Name: /2.% 2 Title:��— , A copy of this exemption and a tracking document shall he in employee's possession at all times while transporting medical waste. In addition,all copies of medical was shall be kept on file at generator's or health care professional's facility. Applicant Signature. Date: �? 2Z� Title: DO NOT WRITE BELOW THIS LINE R.E.H.S. Application Approval: Vn_x� Date: j Expiration Date: ll Date Paid: l 3D /0 CashCheck#: �.S/3 Received By: �T EHD 45-61 11/19/09 V., 1 IO Role C� 10147 .