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'H `Q SAN JOAQUIN COUNTY <br /> ENOONMENTAL HEALTH DEPARTART <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd VC-6 <br /> DEC <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTLQN C 4 2009 <br /> 31 =`P N� <br /> To qualify fora "Limited Quantity Hauling Exemption"pursuant to the "Medical Waste Managem g <br /> conditions must be met: pAHTIyFNT <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 $77.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ❑ New Renewal <br /> Medical Office/Business Name: Mkk VYAtntk <br /> Medical Office/Business Address: '� AWL& <br /> Ci State Zip Code <br /> Contact Person: I/i1 m cr Ll �OVI rh <br /> Phone Number: ?le - 6l - L°t'1°,�� <br /> Storage Facility Name: QW&V VtAi*he j <br /> Storage Facility Address: '1�'2,b �4i <br /> City State Zip Code <br /> Permitted Treatment Facility Name: �a�lXl Glb <br /> Permitted Treatment Facility Address: Gln f <br /> — <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: SuUAN UrYkt(o Title: <br /> 2. Name: �lill►�t Gh�r>^I r1�t0 Title: VhA Girt <br /> 3. Name: 611N G1Gt'tfii4r-- 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: �(,h d �i1� Date: 12. <br /> /61y, <br /> Title: ALI "LLfto✓ <br /> it V <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: .�.,.9�-e�;-1�. Q.J,,._. Date: ,17--/ <br /> Expiration Date: 1-L / / b Date Paid: -112: / ILLO-1 Cash or(—eck 3 3<6-'b Received By: � <br /> EHD 45-0I <br />