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r oPQuIN c c ,•. .�,E•..oG SAN JOAQUIN COUNTY D ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 DEC 19 2011 (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd ENVIIIUNMENT HEALTH APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION-RMIT/SERVICES 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, transports 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 Waste 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 Waste Hauler Information ❑ New /Renewal Medical Office/Business Name: T 6/P(S /kS,9i•k'Jef 74-«;-- Medical Office/Business Address IZb•S 6�-. Aliy-lh 9/ • _ lnezn �e.ee— CR 56 City State Zip Code Contact Person: Corn-)f.;� Phone Number: 2e,1) Storage Facility Name: DOGfi>r� +,p�/�/ �• /rj�� '�� Storage Facility Address: t)-j-zn fee� �'� 9533Po City State Zip Code Permitted Treatment Facility Name: S-k n e f/c Af, -JL/1 c . Permitted Treatment Facility Address: /35 w.- .S w i f'f e, Vire.s a o City State Zip Code List all employee names and titles authorized to transport the medical waste (If more than 3, attach info): 1. Name: _ my y X Sch a//Z Title: i gee-&Y C n✓i rct?nieiY fq.1 .Ser w cu 5 2. Name: 61 e✓ri a u,'nn Title: /9 M 1 Lead &u se ap r 3. Name: Title: A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In addition,all copies of medical waste records shall be kept on file at generator's or health care professional's facility. Applicat Signature: a�� Date: Title: r DO NOT WRITE BELOW THIS LINE REHS Application Approval:-7 ` n /� Date: �J�/,(,L Expiration Date: / �) / `Date Paid: 1�/ �1// Cash o Check#: -A64eceived By: _ EHD 45-01 11/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION