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SAN JOAQUIN COUNTY <br /> ENWONMENTAL HEALTH DEPARTAT <br /> ' 600 East Main Street, Stockton, CA 95202-3029 <br /> r a Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd <br /> APPLICATION FORA 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 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:/0[p. <br /> 'ON <br /> San Joaquin County Environmental Health Department F{�. <br /> Medical Waste Management Program Q1� <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Medical Waste Hauler Information SAN30P0`\14ew <br /> ENVIR pEPPRZM�N� <br /> ❑New Renewal <br /> Medical Office/Business Name: oGk�� �t 2E U�PT1�/ltJ <br /> Medical Office/Business Address: qzS til Ct_t 'i� Dem <br /> S iDC_E__rn7_.l CA 9S2,02— <br /> city <br /> S2L7ZCity State Zip Code <br /> Contact Person: CAF'TA I/-,� J t M W C>L P <br /> Phone Number: -3� ^ EY::>12. <br /> Storage Facility Name: 'N <br /> Storage Facility Address: <br /> 4— <br /> C_Lai cam. <br /> City State Zip Code <br /> Permitted Treatment Facility Name: 1, <br /> Permitted Treatment Facilitv Address: �i t 3 5 _ cSc..1 ��►L� <br /> �SnJo Com- c! �7 2� <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: Title: VA-6 � � �.Srti ► <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 hall ton a at generator's or health care professional's facility. <br /> Applicant Signature: j' Date: <br /> Title: MMS <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: — Date: AL/ ,Z_�4 <br /> Expiration Date: I }./_ / i D Date Paid: / 4 Cash r Check#• JD-746-09 Received By: l�Gt <br /> EHD 45-01 <br />