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. . ''coG SAN .�OA IN COUNTY <br /> :fir- •. ENVIRONMENTAL HEALTH ®EPARTMENRECEW <br /> '• 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> • ��' ` � (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehdDEC 16 2013 <br /> ctFi3" <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXVWLV <br /> l <br /> PERMTf � <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 /> 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 O T�L <br /> Medical Waste Management Program <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Medical Waste Hauler Information <br /> ❑ New ❑ Renewal <br /> Medical Office/Business Name: v <br /> Medical Office/Business Address t'1 <br /> city State Zip Code <br /> Contact Person: VI<O( A-VeAlfw- <br /> Phone Number: —350 <br /> Storage Facility Name: �7 , <br /> Storage Facility Address: akliccr- cis <br /> City State Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: <br /> City State Zip Code <br /> List all employee n mes and titles authorized to transport the medical waste(If more than 3, attach info): C <br /> 1. Name: -A� Yn \At(�S Title: GVYA <br /> 2. Name: W, Title: <br /> 3. Name: Title: . <br /> A copy of this exemptiI) a frac Ing ocu tshat b in employee's possession at all times while transporthig medical waste. In addition,all copies of <br /> medical waste recordsa Opt n erato r health care professional's facility. <br /> Applicant Signa urDate: X2 j <br /> Title: VV <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: Date: __LL/,Lq_/C3 <br /> Expiration Date:-/1/ t 3 ate Paid: 11-5 C k#: Received By:_146L <br /> EHD 45-015/2112 �4,t D q 572APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />