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SAN JOAQUIN COUNTY <br /> h 3 Ali ENMENTAL HEALTH DEPART <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> XI <br /> \6 ;/ Telephone:(209)468-3420 Fax: (209)468-3433 Web: www.sjgov.org/eh <br /> fIL E Co <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 /> € F- 'N <br /> Please complete the information below and mail with $77.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program t <br /> 600 East Main Street, Stockton, CA 95202-3029 SAN :01ADiU1tq GOUN(Y <br /> EN if �iVrrtkt3TA1:.. <br /> Medical Waste Hauler Information HULTviL)E RTMENT <br /> ❑ New XRenewal <br /> Medical Office/Business Name: 14'r-`l rc'h Hrr4 N tier . ,P Cn-4�f <br /> Medical Office/Business Address: 1110 <br /> Me'24C6� lf 9S S() <br /> City State Zip Code <br /> Contact Person: /v1 <br /> Phone Number: f S22 —q6 Z. <br /> Storage Facility Name: 1" ��c�rr�►, � y /P�e �. <br /> Storage Facility Address: 1 l f D -r6s/(, SUf <br /> 10 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: 5 6e+^r <br /> Permitted Treatment Facility Address: <br /> f?A 23--) 2--2— <br /> City <br /> 3-72-"ZCity 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: RL) <br /> 2. Name: b Title: &A� <br /> 3. Name: 0( Title: <br /> �a��� div <br /> A copy of this exemption a a trackin documel t shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical waste ec rds shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: Date: 117, -7 <br /> Title: , r <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: +- `�^- � Date: AZ Tf- W <br /> Expiration Date: 17, / / 11 Date Paid: / / ? Cash of Check :c� Received By: <br /> EHD 45-01 <br />