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SAN JOAQUIN COUNTY <br /> ` ` s EN*ONMENTAL HEALTH DEPARTIOT PAYMENT <br /> r � < <br /> 600 East Main Street, Stockton, CA 95202-30 9, '! p"AFI\/Fr) <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgV,o /eh �; 1 1 2007 <br /> 4��ppY2N <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIONEN IRONnnNTAL COUNTY <br /> HEALTH DEPARTMENT <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$72.00 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 Menewal <br /> Addus Healthcare <br /> Medical Office/Business Name: 817 Coffee Rd ® R1dB� <br /> Medical Office/Business Address: ��,"a��tv�� 9535 <br /> State Zip Code <br /> Contact Person: <br /> Phone Number: <br /> Storage Facility Name: AdduS Healthcare <br /> Storage Facility Address: 817 CoMe g BI <br /> City 9 a e Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: <br /> City State Zip Code <br /> List all employee name nd titles authorized to transport the medical waste(If more thin 3, attach mf <br /> 1. Name: d Title: <br /> 2. Name: 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 records shall be kept on rile at generator's or health care professional's facility. <br /> Applicant Signa Date: oZ <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: / /1 <br /> Expiration Date: 'L/ / Date Paid: Check �73 6 3 Received By: <br /> EHD 45-01 <br /> 10/02/07 <br />