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if I W 0 PAYMENT <br /> SAN JOAQUIN COUNTY RECEIVED <br /> y} ENVIRONMENTAL HEALTH DEPARTMENT <br /> FEB. 2 6 2009 <br /> 1„ 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone.(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <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$77.00 fee to: //�� <br /> San Joaquin County Environmental Health Department P 4 5'5-'7 rA Oal 4S1 Z <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: ST f 1-Ira /fti �(ti M,ti�IZ5 Int oe4 T4-,.-n 14,-q <br /> Medical Office/Business Address: <br /> City State Zip Code <br /> Contact Person: v n /11ki—,0 A <br /> Phone Number: 2 ``- S 7 2- ( — L 5+- ZOO <br /> Storage Facility Name: ,7v,1r,r f" 1-{T4//-Ae:q � <br /> Storage Facility Address: tiC- <br /> (1116�- r3 u <br /> City State Zip Code <br /> Permitted Treatment Facility Name: 5'k P1,; (-& Zn L <br /> Permitted Treatment Facility Address: !J/ ,- 1,0" f17lE <br /> FVSk7C al. � 3',ZZZ <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: 11, 5fcl dl> Title: R N <br /> 2. Name: Title: A <br /> 70 <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 waste r ords shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: Date: ���6 91 <br /> Title: <br /> DO NQjT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: q Date: X / -o!qr <br /> Expiration Date: l2•/-�d-/Date Paid: Z/ %Z to/a ! Cash Received By: ,,SOL <br /> EHD 45-01 <br /> 11/19/08 <br />