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�o SAN JOAQUIN COUNTY <br /> ° � <br /> P 'MENT <br /> =F<1 p I�RONMENTAL HEALTH DEPART*,NT rECEIVED <br /> �O p 600 East Main Street, Stockton, CA 95202-3029 ,� <br /> Telephone: 209 468-3420 Fax: 209 468-3433 Web:www.s ov.or /ehd DEC, 2 <br /> P ( ) ( ) Jg g COUNTY <br /> 5 EN� C�UIN <br /> GNMENENT <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION k, ATN oapz <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 grail 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: U EL Li lvE S Cp G I"�Thi c <br /> Medical Office/Business Address: [ jync (7A it T- �e 0-)Lp, S' ,j,F 2 0 U <br /> O -413 1 <br /> n C <br /> Contact Person: &?C!i_ity L A i\JM A <br /> State Zip Code <br /> Phone Number: 2 i(;�_ S I W S-36 f,?Z-q- <br /> Storage Facility Name: r�A fVj(A �9�, <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: S HAKR (bivlpuA �Nw� <br /> Permitted Treatment Facility Address: 1 WE. I,( F VA61 A �p ESU�•t S iI7 0 <br /> C j'T-�1 A6 E Tom, 3 � <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: +i aC.�\x ri . Title: <br /> 2. Name: Title: <br /> 3. Name: 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 wast records pbe kept on file at generator's or health care professional's facility. <br /> Applicant Signature: `t� Date: 12� /I' U <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: ° �i.-tC Date: _ek/0L/_1v <br /> Expiration Date: 1-2_J Date Paid: Cash Check#• Received By: <br /> EHD 45-01 <br />