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SAN JOAQUIN COUNTY <br /> EN ONMENTAL HEALTH DEPARTT Fz u_ Y <br /> 6 East Main Street, Stockton, CA 95202-302 <br /> c„M_ �P• Telephone:(209)468P9, <br /> -3420 Fax: (209)468-3433 Web: www.sjgov.org/ef 16. E <br /> a�ri oR <br /> 010 <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIOk';�!��� �r�� oury <br /> HFa,LTH ^_I <br /> RV En <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the "Medical Waste Management Act", the followm� <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 $77.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ❑New Renewal <br /> Medical OfficeBusiness Name: Q�\ �� <br /> Medical Office/Business Address: �� S �1e• \ C�.� <br /> City State Zip Code <br /> Contact Person: 'R <br /> Phone Number: S O <br /> Storage Facility Name: SN <br /> Storage Facility Address: 1 '*�AO e- C- <br /> S QAC s O <br /> City State Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: l U �'�. <br /> 5k tl L.tZaq..lo4ae-, CA 945 -m-$ <br /> City State Zip Code <br /> List all employee namees and titles autlloriized to transport the medical waste (If more than 3, attach info): <br /> 1. Name: 1��C1� � V��� Title: <br /> 2. Name: G Q Title: <br /> 3. Name: 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 <br /> addition,all copies of medical w ste records shall be kept on file at generator's or health care professional's facility. <br /> &djh I 1 <br /> Applicant Signature: C4 Q IL'�/ Date: - AD -�� <br /> Title: �'- S �C�� <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: -6-1 / / <br /> Expiration Date:�/3 /�_Date Paid: Gash-er Check#: 5 Received By: VARs-- <br /> EHD 45-01 <br />