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au ,Y SAN JOAQUIN COUNTY <br /> = 2\ ?1L <br /> ENONMENTAL HEALTH DEPARTM PAYMENT <br /> ! ' ' 600 East Main Street, Stockton, CA 95202-302 Cop RECEIVED <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd I JAN <br /> - 5 2011 <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIONEkyROr;MEc°o"T� <br /> HEALTH DCPARTAtC�j i. <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 4. <br /> 2. Information Document if the generator or parent organization is a small quantity generator not required- <br /> to <br /> equiredto register pursuant to Chapter 4. <br /> Please complete the information below and mail with $77.00 fee to: V71 - <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ❑ New p'Renewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: <br /> Unde n (-,-.Pr 615��Ug <br /> City State Zip Code <br /> Contact Person: <br /> Phone Number: <br /> Storage Facility Name: L..tii1 ien &te eAnta CL <br /> Storage Facility Address: i I X - <br /> 1 n d Pt-) 0_,� Q 6x1362 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: <br /> _ 1 <br /> City State Zip Code <br /> List all employee names and titles�a}uthorrized to transport the medical waste (If more than 3,attach info): <br /> 1. Name: ( f IcIQ t , 1 ��t� jk 11'1 s Title: Rsr�-_�hnra��UL(5el <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 health care professional's facility. <br /> Applicant Signature: Date: <br /> Title: i'kiiMwa <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: + Date: 01 /10 /mik <br /> Expiration Date: /3 /�Date Paid: ` / S /_1�_-Casl-o&Check#:S 2.23(ol S Received By: <br /> EHD 45-01 <br />