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oA4`'I" SAN JOAQUIN COUNTY <br /> ,.... ENVIRONMENTAL HEALTH DEPARTMENT <br /> ` 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> A. <br /> a�P (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <br /> � R <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: <br /> I <br /> San Joaquin County Environmental Health Department WPID� <br /> Medical Waste Management Program (� <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> A <br /> Medlcal Waste Hauler Information <br /> ❑ New ARenewai Addus Healthcare <br /> Medical Office/Business Name: 817 Coffee Rd ® R1101Bt <br /> Medical Office/Business Address d in <br /> Modeso, %-.A95355 <br /> Cir8tpte Zip Code <br /> Contact Person: <br /> Phone Number: <br /> Storage Facility Name: Addus Healthcare <br /> Storage Facility Address: 817 ,ter e Rd <br /> City Odep <br /> Gladd <br /> Permitted Treatment Facility Name: r Modesto, CA �5355 <br /> Permitted Treatment Facility Address: <br /> 7• <br /> City State Zip Code <br /> List all employee nam and titles aLghorized to transport the medical wa (If giore than 3, attach info): <br /> 1. Name: 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 addition,all copies of <br /> medical waste records s11a t on file at generator's or h alth care professional's facility. <br /> Applicant Eisinatur Date: <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> __W <br /> REHS Application Approval: k— Date: &_/til <br /> Expiration Date: L/N/ 1?2 Date Paid: I 1 /.3 Cash or heck MaLO-Received By: -V <br /> EHD 45-01 512112 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />