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°A4u�N' � O UIN OUNTY P,4 <br /> �p ENT <br /> -err y 'ECE <br /> ENVIRONMENTAL HEALTH DEPARTMENTAill" FD <br /> -^• East Hazelton Avenue, Stockton, CA 95205-6232 DEC13 - <br /> 1868 ZQ <br /> (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd oaQu#j <br /> G/FOR y � <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION 61 ' 4r <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, transports 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 or a <br /> 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 to <br /> register pursuant to Chapter 4. <br /> Please complete the information below and mail with $77.00 fee to: P: ° W7E—NT <br /> RECEIVED <br /> San Joaquin County Environmental Health Department APP1R0V <br /> Medical Waste Management Program r� ' �.�L . Lb�l <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTt,IEN1' <br /> � Medical Waste Hauler Information <br /> ® <br /> ❑ New '�Renewal <br /> Medical Office/Business Name: ` <br /> Medical Office/Business Address <br /> Ci y Sta e Zip Code <br /> Contact Person: <br /> C G' <br /> Phone Number: <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: <br /> 0 <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste(If moxe than 3, attach info): <br /> 1. Name: Title: <br /> 2. Name: 4Title: <br /> 3. Name: "" Title: <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while ransporting medical waste. In adds ion,Vall copies of <br /> medical waste records shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: �2� = Date: 1117e ,1 <br /> Title: <br /> 1/7 <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: � .- C��. � _ Date: M/ .1./ 11-� <br /> Expiration Date:11,-/ Date Paid: 12-113 /13 Cash or Check#: Received By: a µ"L <br /> EHD 45-01 5/2/12 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />