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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> �q :LLa�P (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> tai 8R <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-pursuant to Chapter 4. <br /> Please complete the information below and mail with $77.00 fee to: r a <br /> San Joaquin County Environmental Health Department vZ j <br /> Medical Waste Management Program , J v <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Medical Waste Hauler Information <br /> ❑ New Renewal <br /> Medical Office/Business Name: C-c-0 <br /> Medical Office/Business Address ur"TT-ecmtkIf"i CA 19X-X&( <br /> s` ' <br /> City ` State Zip Code <br /> Contact Person: SSR- i1wL joA016 <br /> LZ Oc5-2- <br /> Phone Number: 73 <br /> Storage Facility Name: to �� e�� ( ►�I`C <br /> Storage Facility Address: L_ zo <br /> city IF MIL <br /> State Zip Code <br /> .�Fler.-ril ted i reafinenl%Facility Name: <br /> '�+�1 l� <br /> Permitted Treatment Facility Address: u%7 K <br /> PWC--ft tLOD Wr C40r 7 `z_ <br /> city State Zip Code <br /> List all employee nam sand titles authorized to transport the medical waste fif more than 3, attach info): <br /> 1. Name: IC Title: ' <br /> 2. Name: - Title: lel <br /> 3. Name: --C— Title: <br /> A copy of this exemption and&tracg nt hall be in employee's possession at all times while transporting medical waste. In addition,all copies of <br /> medical waste records shall ben a 'f-thealth care professional's facility. <br /> Applicant Signat.u�re: Date: -(� ` ENI <br /> Title: Dio-e ,A +v''f� RECEIVE[ <br /> DO NOT WRITE BELOW THIS LINE FEB 18 2414 <br /> RENS Application Approval: � Date: t` / AN JOAQUIN COUNTN <br /> ���'77f"""EPMRONMENTAL <br /> _ HEALTH DEPARTMEN9 <br /> Expiration Date: /�/�Date Paid: A 1✓9 lJ Cash or, M-- <br /> heck# ay5 Received By: <br /> EHD 45-015/2112 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />