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SAN JOAQUIN COUNTY <br /> EN�NMENTAL HEALTH DEPARTI�T <br /> % . _ ��. <br /> 60 East Main Street, Stockton, CA 95202-302 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 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, 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 $77.00 fee to: <br /> San Joaquin County Environmental Health Department ' <br /> Medical Waste Management Program <br /> 1 et <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> SAN �UIt�COUN,n' <br /> EN Jit,ONIN1ENTA <br /> ❑ New [ Renewal ��Etlt:;:-i pEPARTIt�EPrr <br /> Medical Office/Business Name: ZiC61 /L7D <br /> Medical Office/Business Address: k,�11>o <br /> City State Zip Code <br /> Contact Person: �4 )-j2 -)- <br /> Phone Number: <br /> Storage Facility Name: ,✓; —u �`P l yP C gme) <br /> � <br /> Storage Facility Address: /-k' 1/j.. ` �C & o A/ L� bOPAD 0 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Yr L /�l. 5 <br /> Permitted Treatment Facility Address: <br /> 17 ' c� 939 z2 <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: Cr c Title: <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: Date: l <br /> Title: /-i 1) <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: A—Z/ /j/–/A <br /> Expiration Date: 11/ -51 /it Date Paid: Lgj 1:5 Cash or�hec #:42 Received By: <br /> EHD 45-01 <br />