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SAN JOAQUIN COUNTY <br /> _ ? EN*ONMENTAL HEALTH DEPART <br /> y {� L EPyyAdENT <br /> 600 East Main Street, Stockton, CA 95202-3029 CEIYED <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web: www.sjgov.org/ehd JAN <br /> �crFaR?� 2011 <br /> ` � Q <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION '4 F"J�A,0),U,rN,10,u, <br /> HF��rH CEPA TMgL <br /> �P <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: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ❑ New Renewal <br /> Medical Office/Business Name: Ve.(m a-nrw� (y\A.(4e-c& to U-`=-\k-a-' <br /> Medical Office/Business Address: -l�l \) . q o <br /> OWt-}e c a Cit(-, cis 3377 <br /> CityState Zip Code <br /> Contact Person: I;r-04+ rDD:aSS1 <br /> Phone Number: aim — 1259- 762) p <br /> Storage Facility Name: i Stw 'PefW\O n e.,yiti <br /> Storage Facility Address: Q. LApseenz <br /> "44ceN CIA S33-7 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: 41 w;- <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:��C.p��o"rri S Title: Q�(- <br /> 2._Name:Imam alun__ Title: _ . <br /> 3. Name: 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,all copies of medical wasteFtprds shall be kept on file atgenerator's or health care professional's facility. <br /> Applicant Signature; Date: 1'7,f-7/-1�l <br /> Title: ' <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: ^ Date:0j—/0 <br /> Expiration Date: �2/�/ Date Paid: �/ 3 / _ Check • d Q-Received By: (� <br /> EHD 45-01 <br />