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e � SAN JOAQUIN COUNTY <br /> ENvrRONMENTAI,HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax:(209)468_3433 Weh:www.sigov.org/ehd <br /> APPLICATION FOR A LIMITED UAN I 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 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 /> I. Medical Waste Management Plan if the generator or parent organization is a targe 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$72.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 <br /> Medical Waste H2ulPr Information <br /> []New ® Renewal <br /> Medical Office/Business Name: Do cto!ca sp° ¢.P <br /> Medical Office/Business Address: '2-gC 0. WOA±A 5,0r"7 <br /> Contact Person: <br /> City State Zip Code <br /> 1292 rim.9 <br /> Phone Number: _2 0 4- 6 <br /> Storage Facility Name: 0v 1®mss ®s <br /> Storage Facility Address: /a a S e f3a <br /> .v a <br /> City State Zip Code <br /> Permitted Treatment Facility Name: t <br /> Permitted Treatment Facility Address: Y3ir e.IJ, <br /> 23722 <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: /Oa X u S el, .A.- Title: <br /> 2.Name: Title: <br /> 3. Name: ,v d, ,G aG..s o�tJ ti 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,211 copies of medical waste records shall be kept on file at generator's or health care professional's facility. <br /> Applica Signature: Date: Z / p`�i <br /> Title: <br /> DO NOT WRI 'T'E BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: <br /> Expiration Date: / / Date Paid:—/—/—Cash or Check#: <br /> Received By: <br /> EHD 45.01 <br /> 07/31/06 <br /> t -d 8zg{,{,Zgg wa-4sRS uvzgew.ao,}uI eL0 :80 LO OZ qaj <br />