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�oPq '",.co PAYMENT <br /> ` EN0SAN JOAQUIN COUNTY EIVED <br /> 6NMENTAL HEALTH DEPART <br /> 304 East Weber Avenue, 3`a Floor, Stockton, CA 95 - 2004 <br /> �P Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.s� v.or d <br /> Q�iFORr' SAN JOAOUIN COUNTY <br /> ENVIRO�ARTMENT <br /> MENTAL <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPT O <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 $70.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 304 East Weber Avenue, P Floor, Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> ❑ New Renewal <br /> i MCC/)wln.-r-44,e Ar- +p mml Arm a <br /> Medical Office/Business Name: �/A16f Q��iLt�1 �. SLC' I-I &mh4g-A <br /> Medical Office/Business Address: �7,$,S`�tt fM,na,r;4v - A:*p, <br /> LDL, 1 0 9� s <br /> City State Zip Code <br /> Contact Person: Ing Ate &tzl cti <br /> Phone Number: jy meq— 766 <br /> Storage Facility Name: Lock. 11'2t M i A 4:� <br /> Storage Facility Address: 1 <br /> GacCc <br /> City State Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: <br /> r �v� <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 S14,1 ature: GG Date: <br /> Title: <br /> DO N OT WRI E ELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: !Zje/ <br /> o <br /> Expiration Date: I Z/ J?'1 /O J Date Paid:�l�/f� Cash o eck 53 Received <br /> EHD 45-02-001 <br /> 10/7!2003 <br />