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�" .co <br /> SAN.JOAQUIN COUNTY <br /> ENOONMENTAL HEALTH DEPART ' E <br /> � <br /> f I L <br /> 600 East Main Street, Stockton, CA 95202-3029 , <br /> P Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd ®V <br /> 2 92007 <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIONEniv/Ro/V COUN7y <br /> HEALTH DEPAqA/TAI- <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management Act", the fo1�o4Yi'g <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$72.00 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 Renewal n <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: <br /> City State Zip Code <br /> Contact Person: . <br /> Phone Number:/ <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> City State Zip Code <br /> Transporter <br /> Permitted Treatment Facility Name: Stericycle, Inc. Date <br /> Permitted Treatment Facility Address: ar west swift Ave. <br /> Fress no,Ga X3722 <br /> 59)275-0994 <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: <br /> 2. Name: Title: <br /> 3. Name: Title: <br /> i <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 on file at generator's or health care professional's facility. <br /> Applicant Signature: f Date: <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: 4-4&, ,, Date: /�/- <br /> Expiration Date: I Z/ �✓I / Ob Date Paid: 0 I Gash-er Check#: 6 0 q Received By: G <br /> EHD 45-01 <br /> 10/02/07 <br />