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u <br /> SAN.TOAQUIN COUNTY ECE§ <br /> ENVIRONMENTAL HEALTH DEPARTMENT V <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202-2708 DEC 1 <br /> Telephone:(209)468-3420 Far:(209)468-3433 Web:www.sjgov.org/ehd EPVVI8 4 ?406 <br /> p��D��j,NT yE, <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION M/T/SERVICE H <br /> S <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 /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 <br /> Medical Waste Hauler Information <br /> ❑New ❑Renewal Addus Healthcare <br /> Medical Office/Business Name: 817 Coffee Rd m Bldg B 1 <br /> Medical Office/Business Address: Made to-CA Q S 2 S <br /> State Zip Code <br /> Contact Person: <br /> Phone Number: <br /> Storage Facility Name: Addus Healthcare <br /> Storage Facility Address: <br /> ciVlodesto, Zip Code <br /> .Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: S- - <br /> 9-1f 7�2a <br /> ity State Zip Code <br /> List all employee naniq and titles au orized to transport the medical waste(If more tha 3,attach info): <br /> 1.Name. Title: Y <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 waste records shall be kept on file at generator's or health care professional's facility. <br /> Applicant Si a re: Date: <br /> Title: <br /> DO N T WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: `o� Date: I Z/Zf/o( , <br /> Expiration Date: / Date Paid: /�/�2 Gash-ew Check#:a13 L Received By: <br /> EAD 45-01 <br /> 07/31/06 <br />