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SAN JOAQUIN COUNTY <br /> EWONMENTAL HEALTH DEPARTIONT <br /> - - .•• 304 Eas eber Avenue, 3rd Floor, Stockto 9 02- � I�EC�VNO <br /> C q.7 c Telephone:(209)468-3420 Fax:(209)468-3433 eb. hrS� Ep <br /> Foy DEC - g 20 <br /> APPLICATION FOR A LIMITED QUANTITY U XE �0 04 <br /> To qualify fora"Limited Quantity Hauling Exemption" QU <br /> ENVIRo IN OOUN-V <br /> Q ty g p pursuant to the "Medical Waste Manager'XW�p ,*-rfW owing <br /> conditions must be met: MINT <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.7oaquin 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 <br /> Medical Office/Business Name: h,6ra I o Lot f /4 9� G tZ P1, , ).^V C <br /> Medical Office/Business Address: ( � ( lil/' r V j g S 1 ,5 <br /> Contact Person: City K r: State <br /> 14-�� ` t Zip Code <br /> � s � I <br /> Phone Number: 2 o ct 3 373 —.. 2Z 4 � <br /> Storage Facility Name: p v �/C >� Z-- . G <br /> Storage Facility Address: l d ! o n A-i _ A—v E1 <br /> I <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Sl j C I- s <br /> Permitted Treatment Facility Address: / 7 ttJ{f t7f c c, K �Q„p , s I I <br /> �-N C—Ncv Cog D o L-/Ar- 5`�7 4ts I <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:O K. K 00-14-A46—rO D C S . Title: -A R. k-7---- <br /> 2. Name: o &,A.L AUy}- Title: f-r2T <br /> 3. Name: L Title: <br /> I <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 S' ature: 5 Date: <br /> Title: - Q, y V t So <br /> DO N T WR T BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: <br /> Expiration Date: / /p S/Date Paid: Cash or eck : Received By: <br /> EHD 45-02-001 <br /> 10/7/2003 <br />