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• SAN JOAQUIN COUNTY . <br /> Pf�, 1` E <br /> ENVIRONMENTAL HEALTH DEPARTMENT R E C 1V E L`-'.. <br /> 304 East Weber Avenue,3`d Floor, Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd DEC 0 7 2006 <br /> F o ` <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTOaOCOUNTY <br /> VIRNMNMENTAL <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$72.00 fee to: <br /> San Joaquin County Environmental Health Departmentti <br /> Medical Waste Management Program (CO Lf�— <br /> 304 East Weber Avenue,3`d Floor, Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> ❑New Renewal <br /> Medical Office/Business Name: (Ze� -Foc S P-,All -e 4 k i v� <br /> Medical Office/Business Address: 5L�36 SH-dct-h]t'cl Ci�c.l-e ( �"te A-3 <br /> Sfo c-L+6-n 04 -}s�a o'-1 <br /> City State Zip Code <br /> Contact Person: i vw6 r-ro" <br /> Phone Number: 47 D- y0 S <br /> Storage Facility Name: 5/A <br /> Storage Facility Address: <br /> City State Zip Code <br /> .Permitted Treatment Facility Name: S`114r'l c Lo- <br /> Permitted Treatment Facility Address: <br /> City 5 r�o '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: pe.A A�i &C.k✓�1C ki Title: (Z-K1 <br /> 2. Name: -30y)-e S Title: L -.V" <br /> 3.Name: Dow'O VYicN cu j Title: (W <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 medicste records shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: Q 0., ,�-l �p Date: f a l .4 06 <br /> Title: b4,t e t I Ur oV ()a; i Al Clar-e &-Orvie es` <br /> DO N T WRIT BELOW THIS LINE <br /> R.E.H.S. Application Approva • Date: // q / 0-i- <br /> Expiration Date: ZZ/ -31 / ateP id: 6�, / ( Cashes Check �3 q o s Received By: <br /> EHD 45-01 <br /> 07/31/06 <br />