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AR/,1x+/2011/THU 02: 53 PM DIV OF TRAINING FAX No, 2099377280 P, 001/001 <br /> KC]C 0 pf <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1 J,: <br /> 600 Fast Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ohd y°Fa�,ENjg1�{ <br /> dy �rh% <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,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 flan 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 Informatilon <br /> ❑New Renewal <br /> Medical Office/Business Name: ('r&( mf- sp;;,C e-�,J <br /> Medical Office/Business Address: S )-A , �L IDo, � <br /> �V.-T-Dtr(C- GA <br /> City State Zip Code <br /> Contact Person: V t Ps (ko n aA G <br /> Phone Number: 601 -2— <br /> Storage <br /> Dt -2—Storage Facility Name: C 5-r o t-tc--V-A r.l C-•l a-:e <br /> Storage Facility Address: c k c> SarJar4_.t1 -qE5�. <br /> l`-t- o lc^ro r-A• 3 <br /> City Statc Zip Codc <br /> Permitted Treatment Facility Name: c-. LAMP f <br /> / <br /> Permitted Treatment Facility Address: (; <br /> M. i �. v , �`' N - <br /> �_ <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): <br /> 1.Name: fV-_L.%f& ao DEL.16 jej , Tithe:� 1/J <br /> 2. Name:� rv�c 0 oN A-t- b Title. <br /> 3. Name: j-.(L ( Ak Z-0 fit✓S 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 an file at generator'®or health care professional's fa 'ity, <br /> Applicant Signatur • Date: <br /> Title: C1 Avon NJ <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval. Date: 3/B_/K <br /> Expiration Date: �2. /?+ / L Date Paid: �. /A�k/ Cir Check#: Received By: <br /> ETD 45-01 <br /> It/19108 <br />