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Sep-14-2006 03 : 19 PM M im Healthcare Se 20947726 2/2 <br /> 41 <br /> l� SAN JOA COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,P Floor,Stockton,CA 95202-2708 <br /> 0fF. <br /> (209)468-3420-Fax:(209)468-3433-Web:www.co.san-joaquin.ca.us/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 foIIowing <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$70.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 304 East Weber Avenue,P Floor,Stockton,CA 95202 <br /> Medical Waste Hauler Information <br /> ❑New URenewal <br /> Medical Office/Business Name: r ca.,/ c,,,-, ,��'r�✓,r_G <br /> Medical Office(Business Address: /z ,.A_ <br /> &kd.= C-f gj.A07 <br /> city state Zip Code <br /> Contact Person: , ,,^__. <br /> Phone Number: 20q- Z/7z°a 73 7 <br /> Storage Facility Name:Storage Facility Facility Address: [?,� �✓ .,,�<,E_ /rr &Z4a <br /> S�®mak 1--,4 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: 9 Cr ,.,L - L Tic •- <br /> Permitted Treatment Facility Address: __•/Zg7y— i6-���,_„ �`••,,•,,, <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: jr- L,. �2.11:. Title: AW1 <br /> 2.Name:_ Sc.,z A .."k— Title: <br /> 3.Name: / _dcM,.,sFrsr,..- 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 kept on file at generator's or health care professional's facility. <br /> Applicant Signature: st /-5 Date: 9/2,6� <br /> Title: A Gtr��s 1-2*841 S� ----- - - <br /> DO N RN LOW THIS LINE <br /> R.E.H.S.Application Approval: Date: / <br /> Expiration Date: 17, Date Paiash or Check#: 3 5T 2(®Received By: <br /> EHD 45.02-001 <br /> i0rrn03 <br />