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,oPqurty .co1 of 2 <br /> SAN JOAQUIN COUNTY <br /> ENVII2ONMENTAL HEALTH DEP <br /> 304 East Weber Avenue,3rd Floor, Stockton,CC5.00 RECFAYEENT <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web: / d �E� <br /> DEC 2 <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION 1 ZQQ4 <br /> SAEENtNVJyyOAQUIN COU <br /> To qualify fora"Limited Quantity Hauling Exemption"pursuant to the "Medical Waste ManagemenNIt RWNU <br /> Mng <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: Lawrence Livermore National Laboratory — Site 300 <br /> Medical Office/Business Address: Corral Hollow Road <br /> Tracy CA 95376 <br /> City State Zip Code <br /> Contact Person: Earl Thomas <br /> Phone Number: (925) 423-9676 <br /> Storage Facility Name: Browning Ferris Industries (Stericycle) <br /> Storage Facility Address: 90 N6rth 1100 West <br /> North Salt Lake City Utah 84054 <br /> Cit State Zip Code <br /> (see attached for additional storagcy facility) <br /> Permitted Treatment Facility Name: Browning Ferris Industries (Stericycle) <br /> Permitted Treatment Facility Address: 90 North 1100 West <br /> North Salt Lake City Utah 84054 <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: Joe Salazar Title: Hazardous Waste Management Tech <br /> 2. Name: Don Dearing Title: Hazardous Waste Management Tech <br /> 3. Name: Joe Stonich Title: Hazardous Waste Management Tech <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 onfileat generato's or health care professional's facility. <br /> Applicant Signature: C. Susi Jackson �� L`- Date: V-L- 1` -C, <br /> Title: Division Leader, Operations and Regulato y A fairs Division <br /> DO NO,/T WRITE ELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: <br /> Expiration Date: — /���Date Paid: T,& � ash o eck . pReceived By: <br /> EHD 45-02-001 <br /> 10(7/2003 <br />