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KEW <br /> AQUfN "Oe_ <br /> SAN JOAQUIN COUNTY Ct-rp, Off—Ice- 07— <br /> �^ ENVIRONMENTAL HEALTH DEPARTMENT <br /> ', .• 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> o <br /> (209)468-3420 Fax:(209)464-0138 Web:www_sjgov.org/ehd <br /> ��.. . <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify fora Limited Quantity Hauling Exemption" pursuant to the"Medical Waste Management Act",the following <br /> conditions must be met: _ <br /> .............. ..... . ... ...__. ........ ..... <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: i <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 /> r <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 /> Please complete the information below and mail with $77.00 fee to: t~PAy4f, <br /> AT <br /> San Joaquin County Environmental Health Department APPRO'V'E C11AV6 <br /> Medical Waste Management Program ��� ' <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 ,_' <br /> rHR Nk <br /> Medical Waste Hauler Information o� <br /> 0 New Renewal <br /> I <br /> Medical Office/Business Name: <br /> Medical Office/Business AddressV_ MsIre CR_ <br /> p <br /> �a J <br /> City, State Zip Code <br /> Contact Person: pird'e, �MC MV0 i. <br /> Phone Number: ce Io Mb <br /> Storage Facility Name: <br /> Storage Facility Address: i <br /> City i State Zip Code <br /> Permitted Treatment Facility Name: S '111 A f.JR, <br /> Permitted Treatment Facility Address: i551 S561n 17a'i.M <br /> RT)I lse cst e3 h'7-f� <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: Q,e- (flille"I 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 addition,all copies of <br /> medical waste records shall be kept on file at generatoes or health care professional's facility. 44 11 <br /> Applicant S' natur : --~' Date: <br /> Title: 1 Q <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: _� Date: A/ MIS <br /> Expiration Date: lN/-•Date Paid: 3 //1 /1 3 Cash or Check#: Received By: <br /> EHD 45-01 512112 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />