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10/02/2007 TUE 12: 13 FAX 2094683433 SJC EHD 0002/002 <br /> OPQ�tk'C • <br /> �. .., o • SAN.TOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/chd y <br /> 2007 <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTI0k1,,,',y, <br /> ����b1: r" . 1L,;4—i <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management Act' the k l�"ii ES <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 Ole one of the following: <br /> 1. Medical Waste Management Plan if the generator or parent organization is a targe 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: ECE�VNT" <br /> San Joaquin County Environmental Health Department + <br /> Medical Waste Management ProgramS C 3 2oo7 <br /> 600 East Main Street,Stockton,CA 95202-3029 ANJ0 <br /> Medical Waste Hauler Information HP�t Cjoo IVOIJ N <br /> E(New D Renewal ""few <br /> Medical Office/Business Name: 14E C� N�'rk�C.� r e- -kr\fkc.C°: <br /> Medical Office/Business Address: 32a.,� P/-G.S pe(---f 8-1-�k wJ: Sfr i�y <br /> ,<tarrehta r'o,-QCta✓tet C.4 qs'��'70 <br /> City State Zip Code <br /> Contact Person: 0-v e 0/1 I,Fcs a/ <br /> Phone Number: `1/ta) - 9S3 <br /> Storage Facility Name: HL?a A/h P -h �C.E^J!k Je'r,11 L e j <br /> Storage Facility Address: 3o-ss- J�rispC c� Pci�k .0t' " 0 ZGj 0� <br /> Rclnehea t-",4 I-S-6 I a <br /> City State Zip Code <br /> Permitted Treatment Facility Name: -,ac/e <br /> Permitted Treatment Facility Address: .2 ki 6 / %cei'--#► Ute QED <br /> pct c. ✓eu°r` ?� ��5S <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: Mi 115`akv,- C� ✓tt� - Title: L- ✓4j ` C <br /> 2. Name: I-.Cit✓ b,ci',c fR, Title: %.� <br /> 3. Name: Pq�,M4 4CW(A Title: h <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 medi4caqwte records shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: Date: f 0 2 01 <br /> Title: <br /> DO NOT WR BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: �/j ;--/M�lz <br /> Expiration Date:1Z/�/Q ,D to Pa d: �u / / 0 Cash or eek s Received By <br /> MID45.01 <br /> 10102107 <br />