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SAN JOAQUIN COUNTY <br /> �2 7 .G <br /> O O D *RONMENTAL HEALTH DEPART*NT <br /> (..>;. 600 East Main Street, Stockton, CA 95202-3029 E <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd 0EC <br /> 2 3 2009 <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIOTN IRO Ca y <br /> 1 d.gLTf,RO 1,ENTq� <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the "Medical Waste Management Act", the fo1JorTg <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 Office/Business Name: .� <br /> Medical Office/Business Address: hora <br /> S fir On in <br /> City / State Zip Code <br /> Contact Person: � e�t!P 'is" 1 �A� <br /> Phone Number: 1 n`;� - j 9 a <br /> Storage Facility Name: <br /> Storage Facility Address: ty. <br /> City State Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: 3� ,' ' <br /> 64 <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: --Scrr c1,c _Or Title: 6 Ku- rn1 ! t� <br /> 2. Name: 00 n a <.L hd r►%A Title: l��L>''c /�11 <br /> 3. Name: Title: f1L ctj gfA A3 <br /> A copy of this exemption and t ck n do u�mentshall be in employee's possession at all times ile transpo7`g medical waste. In <br /> addition,all copies of medical a to r or s hall be t on file at generator's or health care professional's facility. <br /> Applicant Signature: Date: 12— Z Z_Ocl <br /> Title: Pcnihsj <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: !,R ) a- Date: <br /> Expiration Date: IZ/-! _/ 1b Date Paid: 1Z /Z3 /d1 Cash or heck 2l S Z Received By: _ <br /> EI-ED 45-01 <br />