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SAN JOAQUIN COUNT <br />y� ENVIRONMENTAL HEALT PAYMENT <br />RECEIVED <br />304 East Weber Avenue, 3rd Floor, St <br />o08 <br />11 <br />Telephone: (209) 468-3420 Fax: (209) 468-3C34org d[)EC 2 ® 2004 <br />�l p0R <br />APPLICATION FOR A LIMITED QUANTITY HAULING EXE "MMCOUNTY <br />NTAL <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 $70.00 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 <br />Medical Office/Business Name: <br />Medical Office/Business Address: <br />Contact Person: <br />Phone Number: <br />Storage Facility Name: <br />Storage Facility Address: <br />Permitted Treatment Facility Name: <br />Permitted Treatment Facility Address: <br />City State Zip Code <br />L/ <br />WE <br />City State <br />• •• <br />List all employee names and titles authorized to transport the medical waste (If more than 3, attach info)- <br />. ?;ane:Title:;- CPJ <br />2. Name: S D,Title: OK - <br />3. Name: S S Title: S <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 medi be kept on file at generator's or health care professional's facility. <br />Applicant Signature: Date: l l ?fit 0 <br />Title: fire,liNtis <br />DO NO rWRITE BELOW THIS LINE <br />R.E.H.S. Application Approval Date: 2/�/Q� <br />Expiration Date: -511D ate Pai /p` (%/ Cash or eck # 02� Received By:— <br />EHD 45-02-001 <br />10/7/2003 <br />