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AQUIN SAN JOAQUIN COUNTY <br /> R� FNT <br /> 2� ENVIRONMENTAL HEALTH DEPARTMENT eFNF <br /> • 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> • FBR`'�P (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehdF�o�Q�g� 1Q�� <br /> H R�pFp"y co, <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION 'qR � <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: <br /> Awoum Payablo <br /> San Joaquin County Environmental Health Department AlpRO <br /> Medical Waste Management Program i JAN 15 2014 <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232Y! <br /> Medical Waste Hauler Information POSTER <br /> ❑ New X Renewal <br /> Medical Office/Business Name: rt /S r�`--s �!/t Jeroa- <br /> 7- <br /> Medical Office/Business Address ct <br /> City a StaN / Zip Code <br /> Contact Person: <br /> Phone Number: _ <br /> Storage Facility Name: ,�/ , RC1l / r Se l-V1c'S <br /> Storage Facility Address: - <br /> Ci��n State Zip Code <br /> Permitted Treatment Facilitv Name: S r-1 az / v <br /> Permitted Treatment Facility Address: <br /> City State Zip Code <br /> List all employee names a d titl s authorized to transp rt the medical waste(If Riore thap 3, a"tt�ch info): <br /> 1. Name: - (r Title: iS'tt/tr IVi.�rS�' <br /> 2. Name: Title: / r <br /> 3. Name: r4-al - J f Title. <br /> tion 1 <br /> A copy of this exem a ticking(�d.o-, rrd fit hall b1 in ploy e s possession at all times while transporting medical waste. In addition,all copies of <br /> medical waste records shall be kept on file at generator's or health care professional's facility. <br /> a <br /> Applicant Signa wre: iJ1-I(bv Date: /:fie`'/0- W.3 <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> -1-ExREHS Application Approval: Date: L-1- <br /> Expiration <br /> piration Date:j / j_/ll Date Paid: / 123//T Cash oC hed : i007-�`i8l Received By: ~ <br /> EHD 45-01 5/2/12 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />