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q' I!Y• <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> ' 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> •:. ..... (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <br /> <<FOR <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 /> register purs4aant to Chapter-4. <br /> Please <br /> hanter4- <br /> Please complete the information below and mail with Vii D _ <br /> San Joaquin County Environmental Health Department VC <br /> Medical Waste Management Programk <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 jj <br /> Medical Waste Hauler Informatlon <br /> ❑ New Renewal <br /> Medical Office/Business Name: Hive,—O fi(nz `f�c�cf c <br /> Medical Office/Business AddressI <br /> City,) State Zip Code <br /> Contact Person: (_;kct <br /> Phone Number: -VA 91f6 <br /> Storage Facility Name: l .vii Lwt (c I' l uF -fy -c-Sahod cW <br /> Storage Facility Address: '?Si P2t) <br /> CityL .`U } � State CA- Zip Code <br /> Permitted Treatment Facility Name: G\-P <br /> Permitted Treatment Facility Address: <br /> City State Zip Code ` 1 <br /> List all employee names and titles authorized to transport the medical wade (If more than 3, attach info): <br /> 1. Name: l��.rol)(cg hf-i,\d y Title: rr�u ff \ _J <br /> 2. Name: i'Yl W 1, �c�i i�c?rq Title: t-a <br /> 3. Name: IA ;t I i n rv\ huh 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 addition,all copies of <br /> medical waste records shall be kept on pile at generator's or health care professional's facility. <br /> Applicant Signature: Date: 12/1-7/12- <br /> Title: <br /> i2Title: r,y u, <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: , Date: o' /1 / 13 <br /> Expiration Date:�/51 Date Paid: / 113 Cash o Check /0�l$�y0 Received By: <br /> EHD 45-01 5/2/12 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />