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U 0 8 20 G 4 13:44 2094683433 FIFTH FLOOR PAGE Flt <br /> A <br /> SAIN JOA QUIN COUNTY • <br /> ENvIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue, V rloor, Stockton,CA 95202-2708 <br /> (209)468-3420.-Far:(209)468-1433.* 1yeb:-%"«v.c6.san-joaquiii.Ca.us!elid <br /> APPLICATION FOR A.LIN-11-YED QUANTITY HAULING EXEMPTION <br /> Tc, qualify for a "Li.mited Quantity Hauling Exempfion"put-suant to the"Medical waste Management Act",the following <br /> corkh tions must be met: <br /> The generator or health care professional generates <br /> less than 20 pounds of medical ivaste per week;transport It's's <br /> than 20 pounds of medical waste at any one time, maintains a tracljng document pursuant to Chapter 6 and the <br /> generator or parent organization has on file one of the fbllo%ring: <br /> 1. Afedical ff'asie.ManagementPlan 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. ,Ii Ybrmation Document if the generator or parent organization is a small quantity generator not required <br /> t'0 register pursuant to Chapter 4. <br /> Pl.ease complete the info,-matjon below and Inafl with $70.00 fee to: <br /> Joaquin County Emqrormental Health Department <br /> Medi.-all Waste INIanagement Program WO <br /> , <br /> 304 East' ebcP r.Avenue, Floor,Stockton, CA 95202 K5 A <br /> Medical Waste Hauler I a Uo r IM a t <br /> ED New �Renewal <br /> .Nledical Office/Business Name: <br /> N!Iedical. OlfflCe/13L!Siness Address: e e- Ult'inpg�j aj- <br /> �jA-3T,0 4) <br /> -A'Camon --- <br /> City Stale Zip Code <br /> Contact Person: <br /> Phone Nlurnber: (2-00-2) 6 <br /> Storage Facility Name: <br /> - <br /> Storage Facility Address: <br /> City State <br /> ZIP Code <br /> Permftt6d Treatment Facility Name.- dt'afA , <br /> — Kos �a OIL <br /> Permitled Treatment Facility Address: '" a j Due <br /> Cita' Zip Code <br /> List all ernployee names and titles authorized to transport the medical waste(if more than 3.,attach info): <br /> I. Mame: �L - , LLk--- Tit]e:k1AEk-4k-L"LLL0.Q LL <br /> 2. Name: Title: ktcki� ��alff it <br /> 3. Name: Title:&L&L—k - <br /> A copy of this exemption and tracking document shall 4e in emplo),ee's possession at all times while transporting medical waste. in <br /> addition,all copies of medical waste records shall he kept on file at generator's or health care professional's facility. <br /> Appii,caxit Sig7iaturc,-: 2j <br /> Date. <br /> Title, <br /> DON T WR. TX� BELOW THIS 1.1 N E <br /> R.E.B.S. Application Approval: a.- <br /> Date: 3 I zZI 6 <br /> Expiration Date;�1:3 <br /> / ate Paid: <br /> Cash c(jCh;c ,T <br /> Rcceived Py:� <br />