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SAN.lOAQUIN COUNTY <br /> EISWONMENTAL HEALTH DEPARTWT PAYMENT <br /> +n <br /> 304 East Weber Avenue, 3dFloor, Stockton, CA 9 2- 8 <br /> r...,, EIVED <br /> C". x P Telephone: (209)468-3420 Fax: (209)468-3433 Web: g .o '.� <br /> 152004 <br /> APPLICATION FOR A LIMITED QUANTITY HAU G Ps JOAQUIN COUNTY <br /> ENVIRONMENT <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the "Medical Waste Manages r;TMV� Al�er@�,jpwing <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, 3dFloor, Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> ❑ New kRenewal <br /> A <br /> Medical Office/Business Name: Lf- <br /> Medical Office/Business Address: <br /> t u <br /> City I State Zip Code <br /> Contact Person: (Z L11y,l�,j 'fVk L <br /> Phone Number: <br /> Storage Facility Name: <br /> Storage Facility Address: wo r-- kz 0 V,�, <br /> City State Zip Code <br /> Permitted Treatment Facility Name: r•y",L �-,� <br /> Permitted Treatment Facility Address: <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: `� ��r�l+� �f b.,Atle: <br /> 2. Name: 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 waste records shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: NDate: (7 <br /> Title: <br /> DO NOT WRIT BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: /-��w/ <br /> Expiration Date: / / Date Paid: / / Cash or heck :�r Received By: <br /> EHD 45-02-001 <br /> 10/7/2003 <br />