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SAN JOAQUr f. 'N COUNTY rk �w l; 7TROMMENTA-L HF-ALTm DEPARJ-..F_NT FILE COPY 600 Em main Street, Stockton, CA 95202-3029 -TdePh0na--(209)4684420 Faxt(209)4684413 Web"%ww.090v APPLICAITON FOR A LZMED QUANTUY HAULING FXElKPTXON To qualiry for a"Litnited Quantity HOWingEXOmption"pursuaw to the 11,. 1 Waste conditions must be met: Mcd.ica Ste Markag=ent Act",the following The Sczerator or bcalth care professional generates less tl)an 20 pounds of medical wastt per,wock,tran8port les, fl"ku 20 Pounds of,mcdical wage at arty one time,maintains a tracking document pursuant to 9morator or parent organization baa on file one of the.r,01jowing., Chapter 6 and the 1, Medical If"asreManagementplan if the scriorator or parelit organization is a large quantity genqrator Or a small quantity generator required to register pursuant to Chapter 4, 2. 1nfbrm,?tjot7))0ajeMenf if the generator or parent organization is a small quantity 8011crator not required to register Pursuant to Chapter 4. Please complete the information below and Mail with$77.00 fee to, SznloaqWn COuntY Environmental Health Department Medical Waste Management Progmm 600 East Main Stroct, Stoddon, CA 95202-3029 0 New X.Renewal Medical OfficeMlIsiness Name.. SLaD_JT_oa u* Count Pub is Heait Medi caj Office/Busineqs Address- 601 czvices East elton Ave on CA 95205 City State 7i Codr ContaOt Person: Nikk' illiams Phone Number: 209)468-8018 Storage Facility Name. San.Jo County Pull H c ealt-b i4aqm— StOtage Facility Address: 1601 Last Ava Stockton f7 A 95205 City State Zip Code Permitted Treatment Facility Name., Storicycle Permitted Treatment Facility Address: 4135-W. S wLft �. 1ve. den _ r,k 95.205 City f-U,5,0,j0 slate� Zip Code List all employee names and titles authorized to transport t1le medical waste(If more than 3, attach infb): 1. Name: See atta-ched info Tit1c: 2. Name, Title.- 3, Name: Title., A copy of this exemption find a tracking docum addition, all copies of inedienj ent'hall be in employee's Possession at all limey while tranvorting medical waste. In -31ste records.9hall be t on file at generator's or henitli care professional's facility. Applicant Signature: Date: Title-, _L;24�— DO N,-QT WRITE BELOW THIS LINE R.E.H.S, Application Approval: =�L , Com.,-t,—_--- _._Date: _LZ/_3) /oq Expiration Date: Dote Paid. Cash or Check#: FM 45-01 Received By: