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oPauly o <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> `�9�tfioR `P (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <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, transports 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 or a <br /> 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 to <br /> ---- - -register pursuant to Chapter 4. <br /> o p <br /> Please complete the information below and mail with $77.00 fee to: <br /> San Joaquin County Environmental Health Department ",110, <br /> JAN 0,2 2014 <br /> Medical Waste Management Program A ENVIRONMENT HEALTH <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 PERMIT/SERVICES <br /> Medical Waste Hauler Information <br /> ❑ New Renewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address 2 p <br /> City <br /> Contact Person: State Zip Coden� <br /> Phone Number: _ <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> City tate Zip Code <br /> Permitted_Treatment Facility Name: 5 fe,,rl G <br /> Permitted Treatrnen±Facility Address: <br /> Z-2-- <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: Title: <br /> 2. Name: r Title: ��11 <br /> 3. Name: h Title: jk ✓) <br /> A copy of this exemption and a tracking document shall be In a yea's possession at all times while transporting medical waste. In addition,all copies of <br /> medical waste records shall be k n file at generator's o alth care professional's facility. <br /> Applicant Signature. �_ Date: 3 <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: _ -a I Al A. <br /> Date: <br /> 9 <br /> Expiration Date: / / 14 Date Paid: 1 l` / l,3 Cash or Check#: Received By: <br /> EHD 45-015/2/12 <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />