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Jan. 22, 2013 12:OOPM San Joaquin County No- 0430 P. 2 ° SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT RECEIVIM 1868 East Hazelton Avenue, Stockton, CA 95205-6232 JAN 2 5 2013 o (209)468-3420 Pax: (209) 464-0138 Web:www.sjgov.org/ehd ENVIRONMENTAL HEALTH APPLICATION FQR A LIMITED QUANTITY HAULING EXEMPTION PERMIT/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, transports less than 20 pounds of medical waste at any one time, maintains a tracking document pursuant to Chapter B and the generator or parent organization has on file one of the following: 1. Medica!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 Docoment if the generator or parent organization is a small quantity generator not required to register pursuant to Ghapter 4. Please complete the information below and mail withi $77.00 fee to: San Joaquin County Environmental Health Department ti>�rMedical Waste Management Program �i�ovr 1868 East Hazelton Avenue,Stockton, CA 95245-6232 Medical Waste Hauler Information ❑ New )&Ienewal Medical Office/Business Marne: Medical Officeli3usiness Address ,1s ✓V C-lav-caw J' Ci SCate Zip Code Contact Person: Phone Number: 20]— _� J t4 Storage Facility Mame: 0' `�f Storage Facility Address. U City State ZipCode Permitted Treatment Facility Dame: Permitted Treatment Facility Address: 1 5 city sla a Zip Code List all employee names and titles thorized to transport the medical waste(if more than 3 attach info): 1- Name: '-7,_-v,/ ,' cam' tom/ Title: 2. Name: Title: 3. Name: Title: A copy of this exemption and a tracking document shall be in employee's possession at all tirraa while transporting medleal waste. In addition,all copies°f medical wasls records shall De kept on file f is or health care professional's facility- Applicant SignaturaGate: Title: .h/is DO IN0TWRiIE 1El_QW THIS LINE REHS Application Approval: ._. .... Date: L 1M/_M Expiratson Date:_I-L IDate Paid:/1 3 1 LI3 Cash or Check#: 1733 Received By: ERD as-ai 5121f2 APPLICATION FOR A LIMITED QUANTITY HADUK0 EXEMPTION