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U <br /> SAN JOAQUIN COUNTY <br /> y { ENMENTAL HEALTH DEPART kT ILA <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> c 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$72.00 fee to: <br /> San Joaquin County Environmental Health Department PAYIVIE <br /> Medical Waste Management Program Rl`(�1;1� �N <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> "�' 1 3 2007 <br /> Medical Waste Hauler Information SANJOAQUINCOONUNTY <br /> ENVIRON <br /> ❑ New ARenewal HEALTH DEPART <br /> MENT <br /> Medical Office/Business Name: �C4n /w) 6:Z4 )'-)Zy <br /> Medical Office/Business Address: 16o Do 0 #/ <br /> S'f yo <br /> City State Zip Code <br /> Contact Person: <br /> Phone Number: Dag <br /> Storage Facility Name: <br /> Storage Facility Address: 4rl <br /> City State IFZip Cohe <br /> Permitted Treatment Facility Name: , <br /> Permitted Treatment Facility Address: r. <br /> CA Q v <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: 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 bekept o file at generator's or health care professional's facility. <br /> I %jc)Applicant Signature: _ Date: o ' <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE / 11 /per <br /> R.E.H.S. A A / <br /> Application Approval: � Date: <br /> Expiration Date: _ Z— 0 Date Paid: 12-/ 13 /v 7 Cash or6ck#• 5440 Received By: <br /> EHD 45-01 <br /> 10/02/07 <br />