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-M0ZSAN JOA COUNTy EZ_L H.EALTji DEPAXOXT 600 East main Street, Stockton, CA 95202-3029 Telephoner(209)468-3420 Fax:(209)468-3433 Web, www.sjgov_0rg/ehd j APPLICATION FOR A LD QUANTrry]ELAULING .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 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 K'aste 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 Environmental Health Department Medical Waste Management Program 600 East Main Street, Stockton, CA 95202-3029 Medical Mante Hauler Information 0 New x Renewal Medical Office/Business Name: SanJoaquinCounty PublicHealthServices Medica] Office/Business Address: —1601 East Hazelton Ave Stockton CA A %,A A 95205 Contact Person- Cityikki Williams State Zip Code Phone Number: (209 468-8018 Storage Facility Name: San Joaquin Public Healt UsAnd—ces Storage Facility Address: 1601 East Hazelton Ave Stockton CA 952_05 City State Zip Code Permitted Treatment Facility Name: --.-Stericycle Permitted Treatment Facility Address: 4135 W. Swift Ave. Stockton CA 95205 City state Zip Code List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): 1. Name: See attached info Title: 2. Name* Title: 3, Name: Title: A copy of this exemption and a tmcldng document shall be in employee's possession at all times while transporting medical waste. In addition,all copies of medical waste records shall be kepkon file at generator's or health re professional's facility. Applicant Signature: 27 Date: — 2/-10/2009 Title: St%ff A. Mrse TV DO N,9T WRITE BELOW THIS LINE R.E.H.S. Application Approval: —Date., Expiration Date: —ai-aLL _Date]daid: Cash or Check#.- Received 13y: