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r <br /> oQQv�"' SAN JOAQUIN COUNTY d <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> R CEI ED <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> '• <br /> `209) `468-3420 Fax: 209) 464-0138 Web: www.sjgov.org/ehd DEC 10 2012 <br /> ORS <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIMIRONMENTAL HEALTH <br /> PERMIT`SERVICES <br /> To qualify for a"Limited Quantity Hauling Exemption" pursuant to the"Medical Waste Management Act', the fol owing <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: <br /> San Joaquin County Environmental Health Department APPRO <br /> Medical Waste Management Program 1 <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <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: <br /> Phone Number: 20J- NLA ' 4 2U <br /> Storage Facility Name: <br /> Storage Facility Address: V <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Y <br /> r ermitied T reatrnent Facility Address: <br /> !qL:Z5 C7 <br /> City State Zip Code <br /> List all employee names and titles aut orized to transport the medical waste(i(ifmore than 3, attach info): <br /> 1. Name: t Q1 Title: <br /> 2. Name: Title: 2 <br /> 3. Name: Title: <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transpo�rt�inedical w st . In addition,all copies of <br /> medical waste records shall be ke ton file at generator's or health care professional's facility. <br /> Applicant Signature: c1- Date: <br /> Title: T <br /> DO NOT VkITE BELOW THIS LINE <br /> REHS Application Approval: Date: 12 UO /(V <br /> Expiration Date: IT / 51 /jS Date Paid: /;L-/ /6/ Cash or hec #:8(C I V 117 Received By:.._, <br /> EHD 45-015/2/12 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />