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"t j <br /> oAQuiy <br /> >: •.o SAN JOAQUIN COUNTY <br /> :GZ1 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> -• 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> C•9��F...... (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <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,transports 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 or a <br /> 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 to <br /> register pursuant to Chapter 4. <br /> Please complete the information below and mail with $77.00 fee to: <br /> San Joaquin County Environmental Health Department APPRO <br /> Medical Waste Management Program <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Medical Waste Hauler Information <br /> ❑ New Renewal Llan Soung, M.D. <br /> 1610 N. Eldorado St. George Herron, M.D. <br /> Medical Office/Business Name: R"Ite 17 1610 N. Eldorado St <br /> Medical Office/Business AddressGAton, GA 96204 Slli1P 17 <br /> Stockton, G.A. guna <br /> City � State —L'p�ode <br /> Contact Person: <br /> Phone Number: <br /> Storage Facility Name: _ Lc;,, ly �� <br /> Storage Facility Address: ` '� Imp <br /> City 'v CA <br /> gtate <br /> Permitted Treatment Facility Name: � _ <br /> Permitted Treatment Facility Address: <br /> J / 1 1 i <br /> 2 71 vv <br /> City State Zip C de <br /> List all employee names and titl , authorized to transport the medical waste (if more than 3, attach info): <br /> 1. Name: L;c,. / Title: 8 b <br /> 2. Name: Title: <br /> 3. Name: V 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 addition,all copies of <br /> medical waste records shall be kept on file at enerator's or health care professional's facility. <br /> Applicant Signature: Date: <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: Date: <br /> Expiration Date: dt /�/6 Date Paid: /2 Cash or hec : 4,7Z2— Received By: <br /> EHD 45-015/2/12 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />