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SAN JOAQUIN COUNTY <br /> ENVlkWENTAL HEALTH DEPA <br /> C P <br /> lim[L# ir <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> LiM, -3431 Web: www;s�gov.org/ehd <br /> Telephone:(209)468-3420 F". (209)4458 <br /> ... 3i <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIONS A IN,J 0,' ",4 COUNTY <br /> 'roquaiiry 1'4jr a"Limited Quantity Hauling Exemption"pursuant:to the"Medical Waste Management Act" 1by,IOEN-r <br /> conditions must be met: <br /> .Fhe generator or health care professional generates legs 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 /> gmeratOr 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. hif6rination Doctuntent 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$77.00 fee to.- <br /> San Joaquin Coutnty. Environmental Health DepArtwent <br /> Medical Wasic Management Ptogran-. <br /> 600 East Main Street,-Stockton,CA 95202-3029 <br /> Medical Waste Hauler Information <br /> F"I New LX Refiewal <br /> Medical Office/Business Name; 41'e-tH LI.-r- V1 Ir <br /> Medical Office/Bugiiiess Address,- 1-1-7t bri. C I In, <br /> City State Zip Code <br /> Contact Person: Lot /44-j Le'1Z <br /> Phone Number: <br /> Storage Facility Name: ock, 41-11. <br /> Storage Facility Address:- �Z. 41"C L <br /> t <br /> Stae <br /> City Zip Cod <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: q1 <br /> C <br /> City State Zip Cote <br /> List all employee name's and titles authorized to transport the medical waste(If more than 3,attach info): <br /> 1. Name, 1 1,0 t Title: xr&itc; 1/11ca-,,A_^[-- <br /> 2. Name: Av,yyk, 40h-,-� Title; ():I-x C4,-� <br /> a <br /> 3. Na.rriq-, Title: <br /> A copy of this exemption and a tracking document shall be in employee's possesston-at all times while transporting medical waste. In <br /> addition,all copies of medical wa records shaft be kept giLkloat.generator's or heAth care professional's facility. <br /> AppliCaatr,Sj'. tore.- Date: It <br /> Title-, <br /> DO NOT WRITE BEL-OW THIS LINE <br /> R.E-H.S. Applidation Approval: Date- 8.jl <br /> Expiration Date: j-Z N j_11 Date-Paid: <br /> Q.-ji-or Check (0 Received By; <br /> EPE)45-01 <br />