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0 <br /> SAN JOA UIN COUNTY 0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3`d Floor, Stockton, CA 95202-2708 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> C fid <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify fQr a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management.Act",the following <br /> conditions must be met: <br /> The Igenerator 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,3rd Floor, Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> ❑New Renewal <br /> Medical Office/Business Name: ecP fAc k m SeFv;t o-s <br /> Medical Office/Business Address: 1776 W. Me.fy.� <br /> S&,kb!!?, C,4 1 S20 7 <br /> City State Zip Code <br /> Contact Person: _•4s4*n Gi"//esD P– <br /> Phone Number: 0 )k-7 73? <br /> Storage Facility Name: m ;nl - e Sea-ti;cec <br /> Storage Facility Address: 1776 w M L..rt <br /> C-A 9 5zc, <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Ran& Cco - Sen -C C-1.4-, <br /> Permitted Treatment Facility Address: J 7S W 100ICTIt <br /> ►za— CC I LIA 11-7-U <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: FIAt Title: R ;so�r <br /> e� <br /> 2. Name: TTi,.�s 4 G;&sgtc Title: ccvu.&fs �c,ti6g- <br /> 3. Name: A&X 6- r sr4 Title: 2euzy�l-cr' <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: 1,7-1,27/G( <br /> Title: co2c <br /> DO NO WRITE ELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: L2-/2?-1/Q(0 <br /> Expiration Date: m/3j /-0-77-Date Paid: Casshh �d�C�hQe�c�k'#: Received By: 24L <br /> EHD 45-01 l " <br /> 07/31/06 <br />