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SAN JOAQUIN COUNTY P-111YMEIN-F <br /> ENVIRONMENTAL HEALTH DEPARTMENT R E 0 f---i <br /> 304 East Weber Avenue,P Floor, Stockton, CA 95202-2708 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> DEC 2 6 2606 <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTI(jWN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <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$72.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 <br /> Medical Waste Hauler Information <br /> El New El Renewal <br /> Medical Office/Business Name: RA b t 6 oJ17—b <br /> Medical Office/Business Address: vi" s;- <br /> 14- F A, - <br /> City State Zip Code <br /> Contact Person: K,0 Z> 7— -!;; R r <br /> Phone Number: ON !3 <br /> Storage Facility Name: AbV,4A2r—CE1:> I'A-JC,1571cl <br /> Storage Facility Address: 4----A I Lj <br /> City State Zip Code <br /> Permitted Treatment Facility Name:5"f.C-'Al C Vr-L P:---,w At i<-o 9 <br /> Permitted Treatment Facility Address: 7-'T A / 7- 0 <br /> AN AIV e3 Mo C dk QL/ <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: 0, Ki Title: .-.. A <br /> 2.Name:- ROV C41— pok- Title: A- <br /> 3.Name: ZTEVAIIEF, Title: A- R <br /> R. <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 ?s <br /> recor all be kept on file at generator's health are professional's facility. <br /> �" <br /> A;e,61:: <br /> Applicant i natu K 12--19,40 <br /> Title: <br /> V <br /> DO NT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: ti-4 Date: <br /> /Z/ - ZZle-1-1 <br /> Expiration Date: <br /> -5-1-/JZ-;�-Date Paid: \(L- -Ga&h-@&Check#: Received By: <br /> EHD 45-01 <br /> 07/31/06 <br />