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qV(N <br /> oG SAN JOAQUIN COUNTY <br /> WA, r '` X E*RONMENTAL HEALTH DEPART NT <br /> FILE <br /> 600 East Main Street Stockton CA 95202-3 Copy <br /> ' '�• 029 <br /> • �:•,> Telephone:(209)468-3420 Fax: (209)468-3433 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, 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 $72.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> O/New Q Renewal <br /> Medical Office/Business Name: cwntru jknx CgrE <br /> Medical Office/Business Address: �J <br /> K. CA 9416R <br /> Contact Person: IE State Zip Code <br /> , <br /> Phone Number: q <br /> Storage Facility Name: 0.0W*W <br /> Storage Facility Address: <br /> OAK byn-el Cf} <br /> City State Zip Code <br /> Permitted Treatment Facility Name: ` <br /> l A4 <br /> Permitted Treatment Facility Address: 1345 Doolittle Drive-Per Dawn Gorden <br /> San Leandro, CA 94577 <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): <br /> 1. Name: � OL'H Z Title: <br /> 2. Name: Title: <br /> 3. Name: Title: <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical wa a records shall be k on file at generator's or health care professional's facility. <br /> Applicant Signature: - � <br /> , Date: 11 l3 <br /> Title: b$& ��C ry�rlQ <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: 4 , eSt.�J— Date: '�(o✓ <br /> Expiration Date: / 3 I /01 Date Paid: I l 7 D8 Cash<Check#• `/3q3 Received By: � <br /> EHD 45-01 <br /> 8/01/08 <br />