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SAN JOAQUIN COUNTY F 3 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202-2708 DEL; 18 2005 <br /> Telephone.(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> SAN,Jo,4OUIN COUN TY <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIO7�ENVIROf�P�ENTAL <br /> ENVIRONMENTAL <br /> 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$72.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 304 East Weber Avenue,3`d Floor, Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> ❑New (Renewal <br /> Medical Office/Business Name: t!j Qy -yt <br /> Medical Office/Business Address: <br /> a--o <br /> City State Zip Cole— <br /> Contact <br /> o eContact Person: ¢ <br /> Phone Number: p <br /> Storage Facility Name: vp- cV-M hA <br /> Storage Facility Address: <br /> City State Zip Code— <br /> .Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: 4UU <br /> �- zL_ o-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: <br /> Title: �'/1, <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 keptn file at generator's or health care professional's facility. <br /> Applicant Signature: =� Date: 5V-04 <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: /2/Zy/Ocq <br /> Expiration Date: / 3,_/Date Paid: jCl <br /> ash or hec Received By: _ <br /> EHD 45-01 <br /> 07/31/06 <br />