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�or t coG SAN JOAQUIN COUNTY P <br /> �f EN&ONMENTAL HEALTH DEPART*T <br /> 95202-302r <br /> RE <br /> cNT <br /> (0 fast Main Street, Stockton, CA 95202-302 �IVED <br /> Telephone:(209) Fax:(209)468-3433 Web:www.s ol [ CoRv1ZOQ9 <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTI(��T�O/jj/'V VNO <br /> DEP ARTME <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the "Medical Waste Management Act", the follolw i <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 <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ❑ New "6enewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: / v <br /> 2J k1l C�4 Sd <br /> City State Zip Code <br /> Contact Person: Ao n 114 G-, no \� <br /> Phone Number: ( - 46 Zs <br /> Storage Facility Name: � ,�t r,., E-7 /l-A Gle— <br /> Storage Facility Address: U ^ C� <br /> City State Zip Code <br /> Permitted Treatment Facility Name: S <br /> Permitted Treatment Facility Address: <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: 6/U r t� run�r Title: R� <br /> 2. Name: ,N, Title: <br /> 3. Name: r- Title: <br /> A copy of this exemption and a trackin document shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical waste c rds shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: Date: �J <br /> Title: III , e <br /> 4.1 <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval��� Date: <br /> Expiration Date: 1 / /J b Date Paid: `Z/��/�Cash o Chec S Received By: <br /> EHD 45-01 <br />