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May, 15, 2014 2: 23PM Arcadia No <br /> KCCIVE® <br /> d SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT MAY 15 2014 <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax,(209)466-3433 Web:www.sjgov.org/ehd ENVIRONMENTAL HEALTH <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,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 a. <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 S77.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical'Waste Management Program <br /> 1868 E.Hazelton Avenue, Stockton, CA 95205-6232 <br /> Medical Waste Hauler Information <br /> ❑ New Renewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: <br /> d <br /> city, State Zip Code <br /> Contact Person: <br /> Phone Number: <br /> Storage Facility Name: /:1IJ <br /> Storage Facility Address: <br /> - e— -snp d <br /> City States zip Code <br /> Permitted Treatment Facility Name: 14 474p <br /> Permitted Treatment Facility Address; W. <br /> l� <br /> �h <br /> City State fipZCd,., ,4 <br /> v? <br /> List all employee names and titles authorized to transport the medical waste(If more than 3,attach info): <br /> 1.Name: 9h Title; <br /> 2.Name: D Title: qz <br /> 3.Name: Z- *i Title: <br /> A copy of tlih oxeuti>tion and a traelcln doewnent shall be in e►nployee's possession at All times while transporting medical waste. In <br /> addition,all copies of medical waste rds shall be 1 n file at generator's or health care professional's facility. <br /> • <br /> Applicant S' tture: Pate,• <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S, Application Approval: 1 - Q ___. Date: O)/491114-1 <br /> Expiration Date:_L/5 I / 14 Date Paid:M/x/15 Cash or Cheek#: '� O Received By: D164, <br /> EH0 45-01 <br /> Received Time May. 15. 2014 11 : 38AM No- 6057 <br />