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0 DOF* PA�ENED <br /> JI - df-( c-0j _ iQ`? I OC7 -©C)O RE <br /> SAN JOAQUIN COUNTY JUN 16 2010 <br /> ENVIRONMENTAL HEALTH DEPARTMENT su+ RE,rr� r <br /> 600 East Main Street, Stockton, CA 95202-3029 ttF►��+o�"RT"�`}�T <br /> � •* ;;' Telephone:(209)468-3420 Fax:(209)468-3433 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 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 register pursuant to Chapter 4. rA DI-AC)((I <br /> Please complete the information below and mail wit $77.00 a to: X 0�3�'`f'SZ <br /> San Joaquin County Environmental Health Department 55 <br /> Medical Waste Management Program I S3S4d 2--- <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Medical Waste Hauler Information <br /> XNew ❑ Renewal <br /> Medical Office/Business Name: T+� `J � !-X LG(i7►' I f <br /> Medical Office/Business Address: +✓ Z <br /> City fU v State Zip Code <br /> Contact Person: <br /> Phone Number: <br /> Storage Facility Name: i'YI.P� <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Ws cLa-L y- �- <br /> Permitted Treatment Facility Address: i )C <br /> City State Zip Code <br /> List all employee names and titles authorized tot nsport the medical waste(If more than 3, attach info): <br /> 1.Name: �Le Title: <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 w ecord shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: i � Date: <br /> Title: ►f1 <br /> DO NOT''-W-W TE BELOW THIS LINE <br /> R.E.H.S. Application Approval: / 1114, , Date: <br /> Expiration Date: C / 3 I /1 Q Date Paid: to l L l(D Cash orheck#• 4�17DYV Received By: <br /> EHD 45-01 <br /> 11/19/08 <br />