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SAN JOAQUIN COUNTY H E ONMENTAL ALTH DEPARTl&T 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 (209) 468-3420 - Fax: (209) 468-3433 - Web: www.co.sanjoaquih.ca.us/ehd M0110001f g, 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 $70.00 fee to: San Joaquin -County Environmental Health Department Medical Waste Management Program 304 East Weber Avenue, P Floor, Stockton, CA 95202 Medical Waste Hay.ler Information ® New Renewal Medical Office/Business Name: Medical Office/Business Address: Contact Person: Phone Number: State Zip Code .to- X17& -NVO / OR EK -'-176 - Si51 Storage Facility Name:ykn-p- etc. a ova Storage Facility Address: City State Zip Code Permitted Treatment Facility Name: Permitted Treatment Facility Address: r�sn o (D City State Zip Code List all employee names and titles authorized to transport the medical waste (If more than 3, attach info): 1. Name:_nj / ain Title: -9S A141 2. Name: Title: 44P 3. Name: fi Title: S 1.2cry so r 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 medical waste records shall be kept on fi'N at generator's or health care professional's facility. Applicant Signature: Title: II .BELOW R.E.H.S. Application Expiration Date: 4i9_/31_/_a2 Date Paid: / / EHD 45-o2.00i r lo Cash or Check #: 23qD'_Z-Received By: