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SAIN A AQUIN COUNTY <br /> { ENNMENTAL HEALTH DEPAI?TT <br /> Po <br /> 304 East Weber Avenue,3`d Floor, Stockton,CA 95202-2708 <br /> cc. (209)468-3420■Fax:(209)468-3433 • Web:www.co.san-joaquin.ca.us/ehd <br /> R�JFO�a` <br /> APPLICATION FOR A LIMITED QUANTITY HAlULING 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 pursu nt to Chapter 4. <br /> 2. Information Document if the generator or parent o ni 'on is a small quantity generator not required <br /> to register pursuant to Chapter 4. <br /> PAYMENT <br /> Please complete the information below and mail with$70.00 fee to: RECEIVED <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program DEC 17 2003 <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> Medical Waste Hauler Information HEALTH DEPARTMENT <br /> ❑ New enewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: ti. Z/a7nAAC JVD S J <br /> - >m 2k <br /> City State Zip Code <br /> Contact Person: S; l,'V Y-- <br /> Phone <br /> --Phone Number: vT_ <br /> Storage Facility Name: Lc �acw, „�';,, S,s,��, w ,x-76 PCwb), �-Ib <br /> Storage Facility Address: / b%Z,,e-_ /�/o A/" &4AR4$o 0/ 7 <br /> Ci State Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: JAY <br /> e L` tv �. <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 /> /� Title: <br /> 1.Name: r,T A A) S�.r h t', b - <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 n file at generator's or health care professional's facility. <br /> i <br /> Applicant Signature: _Date: <br /> Title: 'F <br /> DO NO WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: <br /> Expiration Date:/ Date Paid: / / Cash or eck#: a Received By: <br /> EHD 45-02-001 <br /> 10/7/2003 <br />