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JAESC HEALTH Fax 2093317067 Mar 22 2013 01:10pm P001/001 <br /> SAN JOAQUIN COUNTY J <br /> - < ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> "�►� (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 healthcare 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. Informetion 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 $77.00 fee to: <br /> C <br /> San Joaquin County Environmental Health Department ®�L, MAR <br /> Medical Waste Management Program rj <br /> 1868 East Hazelton Avenue Stockton CA 95205-6232 <br /> lB�r'Sli9ji�ed� tt y _ <br /> Medical Waste Hauler informatlon <br /> r-1.New 0 Renewal <br /> Medical Office/Buslness Name: P -bV1 <br /> Medical Office/Business Address <br /> r-1 D <br /> city State Zip Coda <br /> Contact Person: �-Vbt rtya- <br /> Phone Number: L'; 0 •►`t0$ _ye j: , t -70 7.5 <br /> Storage Facility Name: y 6 <br /> Storage Facility Address: 950 a 12. �X06 <br /> City State Zip Code <br /> - Permitted-Treatment Facility Name: a.9 <br /> Permitted Treatment Facility Address: <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste�(If more than 3, attach info): <br /> 1. Name: b4nn Va-f\o sFsj._ Title: 120 <br /> 2, Name: T Title: <br /> 3. Name: mak*(-a �C�►�A �[ Title: <br /> C'AA,cm Wo check / <br /> A copy of this exemption and eking document shall be in employao's possoss at all times while transporting medical waste. In addition,all copies of <br /> medical waste records II a ite ion fila art'gen s health care profess) a s facility. <br /> Signatur : klC,& Date: JAN 17X013 <br /> Title: r <br /> DO NOT WRITE BELOW THIS LINE <br /> RENS Application Approval: Q," n' Date: 1,f115 <br /> Expiration Date: ji-, fi�t /LDate Paid./l t 71 /3 Cash or Check#:���q ���Received By: <br /> gl R e c e i v e d Time Mar, 22. 2 013 1 :0 6 P M N 0, 2 616 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />