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SAN JOAQUIN COUNTY PAYMENT E ONMENTAL HEALTH DEPART) NT RECEIVED 304 East Weber Avenue,3'Floor,Stockton,CA 95202-2708 2 (209)468-3420•Fax:(209)468-3433 - Web:www.co.san-joaquin.ca.us/ehd DEC oaquin.ca.us/ehd 9 2003 q�tppRa SAN JOAQUIN COUNTY APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPT HO�TH ON NT NT 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,transport 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$70.00 fee to: San Joaquin County Environmental Health Department Medical Waste Management Program 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202Medical Waste Hauler InformatioFo� ❑New VRenewal n Medical OfficeBusiness Name: o f C I�v b4l e6Cp1C 1// Re.5 e Medical OfficeBusiness Address: a 5 T 7 20 L I cA) CA 9K2 i2 CityState Zip Code Contact Person: V. C Phone Number: 9�S-ySy- d T-/3 Storage Facility Name: S m +S /4 b6Ve- Storage Facility Address: City State Zip Code Permitted Treatment Facility Name: ?er/ r(10?0 Permitted Treatment Facility Address: -13LIS 0001� 4l 1 ✓� N pec N- `l3 lgY7 City State Zip Code List all employee namejs and titles authorijSd-to authorized—totransport the medical waste(If more than 3,attach info): 1.Name: Title: Title: 2.Name: Title: 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 re ords 11 be kept on file at generator's or health care professional's facility. Applicant Signature: c/ic Date: 1;h&3 Title: PeU 1VV/1( C' k Rc S {� r DO NO WRILOW THIS LINE R.E.H.S. Application Approval: BEDate: Expiration Date: /J�j -Date Paid:ff—/Sgi/A�Cash or ec : Received By: EHD 45-02-001 10n12003