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ow c\ SAN JOAQUIN COUNTY <br /> nD <br /> IWIRONMENTAL HEALTH DEPAI41IEN <br /> 600 East Main Street, Stockton, CA 95202-3029 �CE1VE J <br /> �c P� Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> DEC . <br /> S 2009 <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIONSAN JOU <br /> N ENVjRONIN COUNry <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the "Medical Waste Management Acr-� x s40� <br /> conditions must be met: T <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 /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ❑ New Renewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: /��I o _. 1)61.x}/) 0 # / <br /> S ol�-f ter, C <br /> City State Zip Code <br /> Contact Person: >2 <br /> Phone Number: <br /> Storage Facility Name: �VIZvo, d _ 6-cl, <br /> Storage Facility Address: //S` IV. Ji'1.4:a 14t 2[nv.I'hn� l 7 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: St,j 1 e <br /> Permitted Treatment Facility Address: l� n+2.4f— <br /> City State Zip ode <br /> List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): <br /> 1. Name: L ' Title: /`II3 <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: 1,2-14j,� <br /> Title: 2 <br /> r <br /> DO NOT WR TE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: <br /> Expiration Date:�'L /It Date Paid: \2- 0'\ Cash or Check#: S 9 q Received By: <br /> EHD 45-01 <br />