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t � <br /> AQ�iN • SAN JOAQUIN CO R D <br /> r <br /> ENVIRONMENTAL HEALTH M U P y <br /> aNJAN 3 0 2012 <br /> �. 600 East Main Street, Stockton, CA 95202-3029 <br /> (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd ENVIRONMENT HEALTH <br /> o •i,�o�R•`P <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION PERMIT/SERVICE <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 /> San Joaquin County Environmental Health Department a.,t) 1 <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ❑ New IVRenewal <br /> Medical Office/Business Name: 1" <br /> Medical Office/Business Address 191 <br /> andeo- <br /> City state Zip Code <br /> Contact Person: <br /> Phone Number: '� — _ L0 <br /> Storage Facility Name: 7�C nne + <br /> Storage Facility Address: Con—y St I I r1eien}C/X:—g� <br /> City State Zip Code <br /> Permitted Treatment Facility Name: (5 <br /> Peri-fAted Treatment Facility Address: <br /> VT <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste (If more than 3, attach inf ): <br /> 1. Name: 't ±(-I(! f' rl_�2 Title: asNi M, - Sr noi <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 addition,all copies of <br /> medical waste records shall b n file at generator's or health care professional's facility. <br /> Applicant Signature: Date: <br /> Title: <br /> nn DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: Date: 40030 Az <br /> Expiration Date: Date Paid: I /'�O/ I Z-Cash or Check#:3U D✓ Received By <br /> EHD 45-0111/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION <br />