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SAN JOAQUIN COUNTY <br /> ` i E ONMENTAL HEALTH DEPART*T FILE C Y <br /> n1 . 16East Main Street, Stockton, CA 95202-302967 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web: www.sjgov.org/ehd <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, 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: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 P"&IE -r <br /> Medical Waste Hauler Information <br /> RECEIVED <br /> ❑ New ❑ Renewal 6 1010 <br /> )AQUr.N coU <br /> • 7NMENTq <br /> Medical Office/Business Name: 'aRENr <br /> Medical Office/Business Address: ass-�.. �✓ . <br /> City State Zip Code <br /> Contact Person: �LJ <br /> Phone Number: T„-To " 7UCS`TJ �eG� amp 1pd� <br /> Storage Facility Name: V /0 <br /> Storage Facility Address: r +B <br /> .2d <br /> City n State Zip Code <br /> Permitted Treatment Facility Name: Y��C <br /> Permitted Treatment Facility Address: <br /> City State Zip Code <br /> List all employee names and titles authorized to tr4n port the medical waste (If more than 3, attach info): <br /> 1. Name: Title: <br /> 2. Name: Title: <br /> 3. Name: ✓ Title: <br /> A copy of this exemption and a tra mg document shall be in ployee's possession at all times while transporting m ical waste. In <br /> addition,all copies of medical waste records shall be ke ton file at generator's or health care professional's facility. <br /> Applicant Signature: Date: ✓ '� -/,J ��l�/I� <br /> Title: � <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: - e - Date: <br /> Expiration Date: 1—/ 421 /_�X_Date Paid: 112 / l�9 /l!l Cash or Eh ckY: Received By: . <br /> EHD 45-01 <br />