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$`�G� SAN J N COUNTY <br /> pti01ONMENTAL HEALTH DEP AR NT a: <br /> a q <br /> *, 0 ast Main Street, Stockton, CA 95202-3 z9 <br /> CC- r Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> APPLICATION FOR A LIMITED QUANTITY 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 /> 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 $77.00 fee to: PAYMENT <br /> San Joaquin County Environmental Health DepartmentRECEIVED' <br /> Medical Waste Management Program x®r: <br /> 600 East Main Street, Stockton,CA 95202-3029 U Lop$ <br /> S E� ROU/�y COUNTy <br /> Medical Waste Hauler Information HEALTHD PaE�� r <br /> ❑ New Renewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: <br /> �t Aj e4 3 <br /> City State Zip Code <br /> Contact Person: C,14 5; 1,14 C eIC-00 <br /> Phone Number: 20 t - 11- Ji l <br /> Storage Facility Name: a 4,5 o 1A;- A e-4 <br /> Storage Facility Address: t.20 i�', &,® �• <br /> City State Zip Code <br /> Permitted Treatment Facility Name: 5 Luz,' L�� j f -77A)c- <br /> Permitted Treatment Facility Address: q f ' °k <br /> F " <br /> �i� 19722- <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: &M xx `:. 1•l-z Title: irfzeT <br /> 2. Name: 6e,&; ",,,.j,, Title: m <br /> 3. Name: 4a"g#4 g,7k.,yo Title: Pte► <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 Signature: - Date: /,,7r - <br /> Title: ��l ft® z s <br /> DO NOT W ITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: / <br /> Expiration Date: _�/ ' / Date Paid: \L- / ash CheckReceived By: NT <br /> EHD 45-01 <br />