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/�� "'•co JAN JOAQUIN (:OUNT <br /> F <br /> � G j ENVIRONMENTAL HEALTH DEP MElR O D 1 !Vis=!Vi' <br /> „ <br /> CE1VED <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> P Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd CLEC 2 8 2009 <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION JOAQUIN COUNTY <br /> ENVIRONMENTAL <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$77.00 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 XRenewal <br /> Addus Healthcare <br /> Medical Office/Business Name: 817 Coffee Rd- - B l.i CEB 1 <br /> Medical Office/Business Address: <br /> Modesto, <br /> Ci Stat Zip Code <br /> Contact Person: <br /> Phone Number: l <br /> Storage Facility Name: AaGUS Healtlicare <br /> Storage Facility Address: Coffee817 - <br /> 7���/(y ryytt <br /> City State Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: <br /> 1 � <br /> City State Zip Code <br /> List all employee na nd titles authonh ed to transport the medical waste(If more than 3, attach info): \ <br /> 1.Name: ./ Title: /) <br /> 2.Name: Title. <br /> 3. Name: Title. <br /> 1oL <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 med' aste records shall be kept on Q at generator's or health care professional's facility. <br /> Applicant S* o Date: Z2ZM,/eQ9 <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: �/01/ Ib <br /> Expiration Date:—L2--/ 3`/10' Date Paid: /0� Cash or Check#: ` 2 Received By: <br /> EHD 45-01 <br />