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SAN JOAQUIN COUNTY <br /> r ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <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 organizatio is a large quantity generator <br /> or a small quantity generator required to register pursuant to Chapter <br /> 2. Information Document if the generator or parent organization is a all 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 Y1 E <br /> Medical Waste Management Program I V <br /> ED <br /> 600 East Main Street, Stockton, CA 95202-3029 1008 <br /> Medical Waste Hauler nformationSANOA <br /> �Vr ®ur�vC®uN�, <br /> ❑ New Renewal LTy°�pA� �T <br /> Medical Office/Business Name: ,tfJ , 741_ <br /> Medical Office/Business Address: `� <br /> r- <br /> City State r Zip Code <br /> Contact Person: f <br /> Phone Number: <br /> Storage Facility Name: : <br /> Storage Facility Address: <br /> ity State Zip Code <br /> Permitted Treatment Facility Name: P�-7 <br /> �� <br /> Per-mit-ed Treatment Facility Address: l F <br /> ito <br /> State Zip Code <br /> List all employee names and titles aut oriznsport 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 trackingords hall be kept o d ment shall be in em enee's p ession at all times while transporting medical waste. In <br /> addition,all copies of medical waste r ce erafo s or health care professional's facility. <br /> Applicant Signature: _ Date: <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: <br /> Expiration Date: / / Date Paid: / / Cash or Check#: Received By: <br /> EHD 45-01 <br />