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i oG SAN JOAQUIN COUNTY <br />-�+ ENVIRONMENTAL HEALTH DEPARTMENT AC►� <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 <br />EID <br />(209) 468-3420 • Fax: (209) 468-3433 - Web: www.co.san-joaquin.ca.us/ehd DEL: 3 <br />APPLICATION FOR A LIMITED QUANTITY HAULING EX-EMPTIGIOUIN CauNT: <br />ENARONMENTAL <br />« HEALTt DF,�A TM <br />To qualify fora Limited Quantity Hauling Exemption,> purl .: t to the Medical Waste Management Act , 4M Glowing <br />conditions must be met: <br />The generator or health care professional generates less than 20 pounds of medical waste per week, transport less <br />than 20 pounds of medical waste at any one time, maintains a tracking document pursuant to Chapter 6 and the <br />generator or parent organization has on file one of the following: <br />1. Medical Waste Management Plan if the generator or parent organization is a large quantity generator <br />or a small quantity generator required to register pursuant to Chapter 4. <br />2. Information Document if the generator or parent organization is a small quantity generator not required <br />to register pursuant to Chapter 4. <br />Please complete the information below and mail with $70.00 fee to: RECEIVED <br />San Joaquin County Environmental Health .Department . <br />Medical Waste Management Programs CUP <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />Medical Waste Hauler Information <br />❑ New Renewal <br />Medical Office/Business Name: <br />Medical Office/Business Address: <br />Contact Person: t a�da oc� e s <br />Phone Number: 9 a <br />Storage Facility Name: Jit Std^ t� <br />Storage Facility Address: 5&Ic��^�.. �P'� �t <br />IF5,Zd 2— <br />City State Zip Code <br />Permitted Treatment Facility Name: <br />Permitted Treatment Facility Address: _ . �1y33' . c,�l . S w ` e . <br />Sin® CA 937Zz <br />City State Zip Code <br />List all employee names and titles authorized to transport the medical waste (If more than 3, attach info): <br />1. Name—Title: <br />2. Name Title: <br />3. Name: Title: <br />A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In <br />addition, all copies of medical waste;records shall be kept on file at generator's or health care professional's facility. <br />Applicant Signature: r�.�.- �'� � Date: / ? 2 ZZL3 <br />Title: kr r dtiNfi'ay.--= <br />DO N T WRI�TA BELOW THIS LINE <br />R.E.H.S. Application Approval: Date: <br />Expiration Date:lJ? ( /Date Paid: Cash or eck .. Received By: <br />11/ <br />EHD 45-02-001 <br />-'MZ0o[2] XHd TT:9T V009/5T/L0 <br />