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i <br /> AgUI SAN JOAQUIN COUNTY <br /> -1.X <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> " "' 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> • cqc (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <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. *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. Info,,,jarion 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 ApPROV <br /> Medical Waste Management Program <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> // Medical Waste Hauler Information <br /> ❑ New W enewal <br /> Medical Office/Business Name: D/S/Y7 C--f <br /> Medical Office/Business Address t-0L,,C)Cgt 14, 3M <br /> City' �• ����f,� Zip Code <br /> Contact Person: (� �J <br /> Phone Number: <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> City State ` Zip Code <br /> Permitted Treatment Facility Name: r <br /> Permitted Treatment Facility Address: �4A 2 11 <br /> -Ra < � ) e-- 619 <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: ✓�RG:r/E _ 1tij �,� Title: "Sc, <br /> 2. Name: 1 L iS G Title: _ .-i <br /> 3. Name: �f rl\AC- Ift" -•- Title: i-K-t, <br /> A copy of this exemption and a tracking document shat be in employee's possession at all times while transporting medical waste. in addition,all copies of <br /> medical waste records shall be keton file at generator's or heWt h care professional's facility. <br /> Applicant SigQature: . ,O �,I0 Date: <br /> Title: i/ aq <br /> -• I - <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: Date: / 17 <br /> -�, 1 <br /> Expiration Date: j Date Paid:// /7/ 1-3 Cash o Check#� bJ23�Lc rZeceived By: <br /> EHD 45-015/2112 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />