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SAN JOAQUIN COUNTY <br /> IRONMENTAL HEALTH DEPALT <br /> 304 East Weber Avenue, 3`d Floor, Stockton,CA 95202-2708 <br /> cq a�P 1 (209)468-3420•Fax:(209)468-3433 • Web:www.co.san-joaquin.ca.us/ehd <br /> C�ppFt <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 all quantity generator not required <br /> to register pursuant to Chapter 4. <br /> Please complete the information below and mail with$70.00 fee to: g PAYMENT <br /> San Joaquin County Environmental Health DepartmentRECEIVED <br /> Medical Waste Management Program OP <br /> 304 East Weber Avenue, 3`d Floor, Stockton, CA 95202 DEC 3 2003 <br /> Medical Waste Hauler lnfoffmation SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> New <br /> ❑ Renewal HEALTH DEPARTMENT <br /> Medical Office/Business Name: . � ( ' 11 l ' <br /> �IL;7CVli VL C j V � <br /> Medical Office/Business Address: 1 Le t U ti <br /> Zoe- <br /> � <br /> Contact Person: <br /> Phone Number: (;3-t,I j q 4 t 9(t; <br /> Storage Facility Name: VauI A-(-AL- i (J Ig Si `j Gk-iii! <br /> Storage Facility Address: 3Lc $ V <br /> City State Zip Code <br /> F <br /> Permitted Treatment Facility Name: �A( `" i (.�k L (-L.-- <br /> Permitted Treatment Facility Address: u k+. G <br /> ),'I L1 <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 /> c <br /> 1. Name: uY� <br /> L ��' V-E_c Ck-_ Title: <br /> 2. Name: 1 ' . <br /> i� Title: <br /> 3. Name: S GRE QQ> t Title: ligC - <br /> si <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 medicalste cords all be ep on file at generator's or health care professional's facility. <br /> Applicant Signature: . . Date: -� <br /> Title: �; <br /> DO N WR T BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: <br /> Expiration Date: � / Date Paid: a l 3/ Cash or Ch6ck#,� (pd 33 Received By: <br /> EHD 45-02-001 <br /> 10/7/2003 <br />