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SAN JOAQUIN CCkJ wiy <br /> ENVIRONMENTAL HEALTH DEPARTM5NT 2 2012 <br /> X <br /> 600 East Main Street, Stockton, CA 96202-3029 <br /> (209)464-0138 Web: www-sjgov.org/ehd ENVIRI)N <br /> (209)468-3420 Fax. MENT HFALTH <br /> PERMIT/SERVICES <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 /> I 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 /> Please complete the information below and mall with $77.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Maftagement Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Informatlon <br /> New Anewal <br /> Medical Office/Business Name., ca-mmil `rtlrz, Qn, <br /> Medical Office/Business Address Sj -re•j 1.3C, <br /> city state Zip Code <br /> Contact Person: .17n I I'm MC41 Il <br /> - <br /> Phone Number: '(C1 I(in L,-a[-4 1 f;; <br /> Storage Facility Name; %_ "yq_, A,0 4414� <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name; i Gid <br /> Permitted Treatment Facility Address: <br /> 1 lwrylyn <br /> C,& 1 <br /> M+57 <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: 5CP, W(MiAeV Title: <br /> 2. Name: Title: <br /> 3, Name: Title: <br /> A Copy of Reis exemption and a tucking document 0all be in employee's possession at all times while transporting medical waste. in addition,all copies of <br /> medicii waste records shall b41-031!an file at generators or health care professional's facility. <br /> Applicant Signature. t (wcl, Date: Io)(n1wil <br /> Title: ffli,<W <br /> MP <br /> D. 0 NOT WRITE BELOW THIS LINE <br /> REHS Application Approval Date: Aw-fIff <br /> Expiration Date: Date Paid: 1 I ' tj i Cash or Check#: ',,-i Received By: <br /> 5HD45-0111129111 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION <br />