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SAN JOAQUIN COUNTY <br /> E&ONMENTAL HEALTH DEPARTMO- 19�aAyrviE__N T <br /> yam`km . 600 <br /> 041 -East.Main.Street,Stockton,CA 95202-3029 RECEIVED <br /> -(209)468-3433 Web: ww.w..sjZov.org/ehd <br /> -�209)469-3410 Fax. <br /> Telephone. <br /> '7' <br /> OEC 0 6 2010 <br /> APPLICATION FOR A LIMITED QUANTITY-HAULING EXEMPTION SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> To qualify fur a-Limited Quantity Hauling Fxcrrtptio.n"pursuant to the "Mcdical Waste N4anagcmenT;Act".FWMMWftTMENT <br /> conditions must be met: <br /> The generator or health care professional generates less than 20 pounds of medical waste per welek,tramport less <br /> than 20 ppundsvof medical waste at any one time,maintains.a tracking document pursuant to Chapter 6 and the <br /> generator or parent organivAtion has on rile one of the.following: <br /> 1. Medicat Waste hfanager4ent Plan if the generator or parent organization iF;a large quantity gcncralor <br /> or a small quantity required to rqgisterpursuani to Chapter 4. <br /> 2. Information Doviintent if the generator or parent organization is a small quantity generator not required <br /> to re ister pursuant to Chapter 4. <br /> Please-complete the Information below and mail with$77.00 fee to. <br /> San Joaquin County. FrIvironinentall Health Deparunent <br /> Medical 'Waste Minagernent Program <br /> 600 East Main Street,'Stockton,CA 95202-5029 <br /> Medical Waste Hauler Information <br /> 0 New Renewal <br /> Medical Office/Business Name: Atefo Lrc"'_C� <br /> Medical Office/Business Address: 1-t. <br /> City State �p Code <br /> Contact Person: t e4�1'\ <br /> Phone Number: Vj,_rj 4:Z 7 J-7Z'7i <br /> Storage Facility Name: 96a <br /> Storage Facility Address:. i-17(4 'LJ <br /> City State :ip(Code/ <br /> Permitted Treatment Facility Name: <br /> permitted Treatment Facility Addrest: 4t t.v, �e%'%44 2j <br /> C c P <br /> City State Zip e e <br /> the medical waste(If more than 3,attach infb)� <br /> List all employee nmne$and titles authorized to transport t <br /> 1. Name, Title: 4ra,vte- <br /> 2. Name- '&Aon,_ Title-, r).f-A c <br /> 3. NamQ,' IRKA,caa Las-er-s", Title: EZ - "J, <br /> A copy of this exemption and a tracking document shall be in employei's posvzpon,At all times ivhlle transporting medical waste. in <br /> P 9 <br /> addition,all copies or medical w mcorcls shall be kept UjW st.generator's or health care proles�ional's facility. <br /> Lop <br /> A ppl*--�tSignaturez /7 Date: f t <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> i1 <br /> R.E.HS. Applidation Approval: Date. qfL11 <br /> ! <br /> Expirat <br /> L7 <br /> *on Date: i Date-Paid: A1,4 lo /A_�._Qdi-w Check#:q ct bO, Received 3 <br /> EMD-45-01 <br />