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/a SAN JOAQUIN COUNTY <br /> AUG <br /> 1 y. ENVIRONMENTAL HEALTH DEPARTMENT G 2066 <br /> i 304 East Weber Avenue, 3`d Floor, Stockton,CA 95202-2708 ENVIRONMENT <br /> (209)468-3420•Fax:(209)468-3433 • Web:www.co.san-joaquin.ca.us/ehd ALT <br /> PERMIT/SERVICES <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$70.00 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 y� <br /> Medical Office/Business Name: p aX",n <br /> 9 <br /> Medical Office/Business Address: 177 /,if, 5—Zr //o <br /> City State Zip Code <br /> Contact Person: ` - <br /> Phone Number: 202- 4/7 7-2 73 7 <br /> Storage Facility Name: '?'La,rc e-ll E eale � Seeeace ip — <br /> Storage Facility Address: 17ZG -7,� A 212 &a <br /> C4 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: //,Y7-;'` i/C_ Rwe/T R� <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: /c,g-,— hn c s Title: A411 <br /> 2.Name: Title: <br /> 3.Name: Title: , e. -- <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 fele at generator's or health care professional's facility. <br /> Applicant Signature: /J Date: X, c//oG� <br /> Title: � ,rrfs /LIQ <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: <br /> Expiration Date: / / Date Paid:3 / 1 / -0�* Cash or Check#:\ `\ Received By: <br /> EHD 45-02-001 <br /> 10/7/2003 <br />