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Aqu/N SAN JOAQUIN COUNTY p <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> � DEC - 9 2011 <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> (209) 468-3420 Fax: (209)464-0138 Web: www% .sjgov.org/ehd ENVIRONMENT HEALTH <br /> cQ�ikpRa�P <br /> PERMIT/SERVICES <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, 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 /> reaister pursuant to Chapter 4. <br /> Please complete the information below and mail with $77.00 fee to: <br /> San Joaquin County Environmental Health Department Ll E <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ❑ New ' Renewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address <br /> City State 'Zip Code <br /> Contact Person: 03" <br /> Phone Number: <br /> Storage Facility Name: <br /> Storage Facility Address: .ZD <br /> City State Zip Code <br /> Permitted Treatment Facility Name: . �40:- <br /> Permitted Treatment Facilitv Address: '_ <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: 1�/ Jn /✓ EZ AI- Title: <br /> 2. Name: Title: 4Z <br /> 3. Name: }�y ,��ES 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 addition,all copies of <br /> medical waste records shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: Date: !0A <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: Date: 12-/t,5/L <br /> Expiration Date: � Z- /t2 Date Paid: � Z'/ "1 A � Cash+eDck#- ZZ Received By:-. A <br /> EHD 45-0111/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION <br />