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SAN JOAQUIN COUNTY PAYMEN_r <br />I T <br />n EAkONMENTAL HEALTH DEPARTCEIVEQ <br />OI 600 East Main Street, Stockton, CA 95202-3029 DEC2 8 2009 <br />T 1 ne• (209) 468 3420 Fax• (209) 468-3433 Web• www s ov or IeM <br />SAN JOAQUIN <br />ENV- ONMENOj YY <br />APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTI Liy DEPARrrvttlNr <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 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 $77.00 fee to: <br />San Joaquin County Environmental Health Department <br />Medical Waste Management Program <br />600 East Main Street, Stockton, CA 95202-3029 <br />Medical Waste Hauler Information <br />❑ New C Renewal <br />Medical Office/Business Name: <br />Medical Office/Business Address: <br />Contact Person: <br />Phone Number: <br />Storage Facility Name: <br />Storage Facility Address: <br />Permitted Treatment Facility Name: <br />Permitted Treatment Facility Address: <br />City State Zip Code <br />—�oVXL KeA8AtQ, <br />(RED �4ig--(A-u <br />City <br />City <br />State <br />State <br />Zip Code <br />Zip Code <br />List all employee names and titles authorized to transport the medical waste (If more than 3, attach info): <br />1. Name: aA r t Q r l Title: <br />2. Name: Title: <br />3. Name: Title: <br />A copy of this exemption and a tracking document shal in employee's possession at all times while transporting medical waste. In <br />addition, all copies of medical waste records shall be)(elKon file at generator's or health care professional's facility. <br />Applicant <br />Title: <br />Date: 2 ; <br />DO NOT WRITE BELOW THIS LINE <br />R.E.H.S. Application Approval: " c(`��i , Date: 6i / e6l 1 e <br />Expiration Date: Z / 3.1 / 1 C Date Paid:Cash r Che :alb �cZ Received By: <br />EHD 45-01 <br />