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y Mar. 23. 2010 2: 12PM COUNTRY HOME CARE • No. 9538 P. 2/3 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> w: < <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> �d Telephone.(209)468-3420 Faux:(209)468-3433 Web.www.sjgov.org/ehd rcca qh <br /> d 'r' SAN 6 Gu <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTI F'9" cO fD <br /> Ty D pNTgINIY <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management Act",the folloug' <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 FILE C <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Medical Waste Hauler Information <br /> El New 04enewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: <br /> K <br /> City State Zip Code <br /> Contact Person: <br /> Phone Number: 1 <br /> Storage Facility Name: <br /> Storage Facility Address: 61V4 U <br /> City State Zip Code <br /> Permitted Treatment Facility Name: 0WCaCjL <br /> Permitted Treatment Facility Address: 1 <br /> __ (ft 77 <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�z g6q1C;(,;( 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 waste records shall be kept on file at generator's or he care professional's facility, <br /> Applicant Signature: Date: a - <br /> Title: �'rlh'I/ <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S.Application Approval:, Date: <br /> Expiration Date: 12/51 pate Paid: A /Q1,/10 r Check#: °)4 Received By: <br /> s11n 43.01 <br /> 11119103 <br />