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SAN JOAQUIN COUNTY <br /> 2 y ENVIRONMENTAL HEALTH DEPARTMENT <br /> ` 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> c9<iFOR��P (209)468-3420 Fax: (209)464-0138 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, 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 /> 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 /> 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: - ?x <br /> San Joaquin County Environmental Health Department A �� , rA°' <br /> Medical Waste Management Program <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 J <br /> Medical Waste Hauler Information <br /> ❑ New Renewal , <br /> Medical Office/Business Name: Aleagoyn� lee ¢ F/ <br /> Medical Office/Business Address 13r75 Sll7-7222 L/2•//!9 <br /> 5,M l_'14? 9111,9:2 <br /> City State Zip Code <br /> Contact Person: q g�u4/� <br /> Phone Number: z/�SJ x.5.7--;2 980 <br /> //eaZ <br /> Storage Facility Name: I` 466 j f f we, 6� � <br /> Storage Facility Address: 13'' 117-7'2/Z Ste•110 4n ex <br /> city <br /> / State Zip Code <br /> siva � <br /> Permitted Treatment Facility Name: Cly �nG <br /> Permitted Treatment Facility Address: J- nq i 1Z <br /> .5 Pte- b <br /> City State Zip Code <br /> List all employee na es and titles authorized to transport the medical waste (If more than 3, attach info): <br /> 1. Name: e n 4' Title: 1?-A/ <br /> 2. Name: d1 Title: / 1 <br /> 3. Name: Title: — <br /> A copy of this exemption anAlaacking docu a shall be in employee's possession at all times while transporting medical waste. In addition,all copies of <br /> medical waste records sha be k6kt on file at a eratoes or healthcare professional's facility. <br /> Applica ignature: Date: <br /> Title: G. <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: f-%t-e'.-- Date: v�L/31 /IZ- <br /> Expiration Date: 117—& //15 Date Paid: 211 /a Cash or heck 3W Received By: <br /> EHD 45-01 5/2/12 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />