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.. V!1y <br />° � c SAN JOAQUIN COUNTY � ' �'�� <br />ENVIRONMENTAL HEALTH DEPARTMENT{'' <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />13 <br />• c' - P (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd DEC 2013 <br />APPLICATION FOR A LIMITED QUANTITY HAULING EXEMIA"NMENTALHEALT�t <br />MIT/SERVICES <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, transports 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 />Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a <br />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 to <br />register pursuant to Chapter 4. <br />Please complete the information below and mail with $77.00 fee to: <br />San Joaquin County Environmental Health Department L <br />Medical Waste Management Program 17 `� , <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />❑ New <br />Medical Waste Hauler Information <br />Renewal <br />Medical Office/Business Name: <br />Medical Office/Business Address <br />Contact Person: <br />Phone Number: <br />Storage Facility Name: <br />Storage Facility Address: <br />Permitted Treatment Facility Name: <br />Permitted Treatment Facility Address: <br />City State Zip Code <br />City State Zip Code <br />List all employee names and titles uthorized to transport the medical waste (If more than 3, attach info): <br />1. Name: Lmdse.,4 Title: 445 L0 <br />2. Name: R "r% '50( rr e , Title: t4 S <br />3. Name: w e�4 Title: H 5 <br />#• KO b er1 de u p e7-&- f+S w <br />A copy of this exemption and a tracking document sh be in employee's possession at all times while transporting medical waste. In addition, all copies of <br />medical waste records shall be kentDil file, or's or health care professional's facility. <br />Applicant S��iggnature: �—Date: /1 "Al 3 <br />Title: Ma ar a at e.i a -' 4:f-" s e le► eesa j r, d-�, per/ ehc s <br />DO NOT WRITE BELOW THIS LINE <br />REHS Application Approval: a.-& N�-- Date: J—/ju/k� <br />Expiration Date: a/ ii! / Date Paid: /% l 3 Cash or Check #: �`�r Received By: <br />EHD 45-01 5/2/12 a Z APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />