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PQ•U I N <br /> SAN JOAQUIN COUNTY <br /> y ENWONMENTAL HEALTH• DEPARTGNT <br /> �. <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202-2708 <br /> FrI-f <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> `gCtppRa . <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 $70.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> ❑ New ❑ Renewal <br /> Medical Office/Business Name: IAV/f � <br /> Medical Office/Business Address: /(0/0 `t _ c� -54- 'Cut� <br /> City f 1 State Zip Code <br /> Contact Person: }—� cue t <br /> Phone Number: Cent 7q <br /> Storage Facility Name: (�9-01 1, <br /> Storage Facility Address: 30 <br /> (r-6 Cih d yC) <br /> City State Zip Code <br /> Permitted Treatment Facility Name: �-Awi %c *- <br /> Permitted Treatment Facility Address: 10390 ��,' <br /> (fid(&,A 0/,I q z 37y <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: t ' Title: D Fh a <br /> 2. Name: Title: fly,_ob-� , <br /> 3. Name: ,Slle���>` Q cwt Title: _ _d teen cw,. as l <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 ;wast ror s shall be kep n file at generator's or health care professional's facility. <br /> Applicant ignature: Date: //-oZ '0 y <br /> Title: t re's I <br /> DON T WRIT BELOW THIS LINE <br /> R.E.H.S. Application Approval: le 1.4 Date: V 3 /D <br /> i <br /> Expiration Date: _f�l�?(_/Q�Date Paid: a/ a / CD 4 Cash or heck#• !q 7 a Received By: <br /> EHD 45-02-001 <br /> 10/7/2003 <br />