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oAau�N' o SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> DEC 21 2011 <br /> m:. { 600 East Main Street, Stockton, CA 95202-3029 <br /> (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd ENVIRONMENT HEALTH <br /> cq'' ,.•��P PERMIT/SERVICES <br /> ��FOR <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, 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. <br /> ollowing: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: 14 9 <br /> � � <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 /> C New Renewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address 41 K <br /> & _Sja�e^ Zip Code <br /> Contact Person: /'� AX <br /> Phone Number: 1 – <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> City State ,, /� ,nZip Code <br /> /� <br /> Permitted Treatment Facility Name: I Y 18 ,/ 0 0S 412 I�(� <br /> Permitted Treatment Facilitv Address: <br /> City State Zip Code <br /> List all employee na es and titles authqnzedJ6 transport the medical waste (If more than 3, attach info): <br /> 1. Name: 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 addition,all copies of <br /> medical waste records shall be ke c file I generator's or health care professional's f Ility. <br /> Applicant Signature: Date: t'2-0!� If <br /> Title: )WO <br /> DO NO ITE BELOW THIS LINE <br /> REHS Application Approval: 1 Date: -j_?L�/. <br /> Expiration Date: ��/�/ �Zi Date Paid:) / � /�Cash o Check -� Received By: — <br /> EHD 45-01 11/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION <br />