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Pp ° �aG SAN JOAQUIN COUNTY • M91=9EM <br /> 2` `' `? ENVIRONMENTAL HEALTH DEPARTMENT <br /> N JAN - 9 2012 <br /> ;. 600 East Main Street, Stockton, CA 95202-3029 <br /> (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd ENVIRONMENT HEALTH <br /> oq�i F oRr'�P PERMIT/SERVICES <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, 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 /> 1. 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 /> rnnictnr no irVuion+to (chanter 4 <br /> Please complete the information below and mail with $77.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program r' t. <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ❑ New 1;--<Renewal <br /> Medical Office/Business Name: Mankr& qt26p,'idLk <br /> Medical Office/Business Address W• D ' <br /> City State Zip Code <br /> Contact Person: inm-ck Number: 1c lv <br /> Storage Facility Name: T A*iw PP. mp-nC✓tk& rn1 Lt1 <br /> Storage Facility Address: /I/ ✓L+Cn. CR 01533'-] <br /> City State Zip Code <br /> Permitted Treatment Facility Name: G �1nC.. <br /> .,i114cd T.oaI'... 11 Fcoility A,ddres <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: Coo AlrzTitle: CVPePLIA <br /> 2. Name: Title: -}e, <br /> 3. Name: Title: V <br /> A copy of this exemption and a trac Ing docum t shall be in employee's possession at all times while transporting medical waste. In addition,all copies of <br /> medical waste records shall be ke n file a e erator's or health c professional's facility. <br /> Applicant Signature: Date: ` <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: �L--- --=�a .E ,yl Date: / /%z— <br /> Expiration Date: �Z /�� / '' Date Paid: ( / / �Z Cash or Check#: Received By:W <br /> EHD 45-01 11/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION <br />