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?°eau t N\` SAN JOAQUIN COUNTY <br /> E1&ONMENTAL HEALTH DEPARTONT 1 L � <br /> 600 East Main Street, Stockton, CA 95202-3029 6 ZOU8 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd kc 1 <br /> Q�r�oR <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTI@MONMENTAL <br /> HEALTH DEPARTMENT <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 /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ❑ New ❑ Renewal <br /> Medical Office/Business Name: G�, <br /> Medical Office/Business Address: Jh A/. trt,b <br /> S V71Zk4 � c f 4 <br /> City State Zip Code <br /> Contact Person: <br /> Phone Number: _ 6 <br /> Storage Facility Name: <br /> Storage Facility Address: a -? , <br /> City State Zip C/de <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: L55 <br /> —fjA.!A&t 1 -CA Z <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: j _ 5 ' Title: /`7.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 s all be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: Date: i/, k <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: )r± Date: <br /> Expiration Date: /Z/51 1,6q Date Paid: \2— / I� /O Cash or hec Sal Z Received By: <br /> EHD 45-01 <br />