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.2010-J2-27 14:32 SUPPM SERVICES 2098253730 2094640138 P 3/3 <br /> ,N <br /> 4: -+ VIRONMENTAL EALTII DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> - M•� . Telephone:(209)468-3420 Fax:(209)468-3433 fVeb:w%vw.sjgov.org/ehd <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management Act", the following <br /> conditions must be met: <br /> The generator or health care professional generates less than 20 pounds of medical%vaste 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$77.00 fee to: <br /> San Joaquin County Environmental Feaith Department <br /> Medical Waste Management Program <br /> 600 East Main Street,Stockton,CA 952023029 <br /> Medical W ste Mauler Information <br /> p New Renewal <br /> Medical Office/Business Name: _ rtant. �Ylan�},eo:�rae <br /> Medical Office/Business Address: 0 e <br /> it State Zip Code <br /> Contact Person: <br /> Phone Number: r959— 363 <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> CAS <br /> City State Zip Code <br /> Permitted Treatment Facility Name: nc <br /> Permitted Treatment Facility Address: 4 <br /> Res= C16 <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 /> I.Name:, oa-� AO�.r S _. Title: (-(-� <br /> ?. Name: a4o <0'r,Q. Title: <br /> 3. Name: 113Y1 <:,�?T -_ aJt 1C_e,,r Title: <br /> A copy of this exemption and a tracking document sliall be in eanployuc's possession at all times white transporting niedical waste. In <br /> addition,all coples of medical waste ords shall be kept on file at enerator's or health care professional's facility. <br /> Applicant Signature Date: I?-L Ll) <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: <br /> Expiration Date: I l Date Paid: / / Cash or Check 1f: _ Received By: <br /> L•14D 45-01 <br />