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° <br /> SAN JOAQUIN COUNTY <br /> --'2{ ENVIRONMENTAL HEALTH DEPARTMENT <br /> •. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> i:aR (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 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. Information Document if the generator or parent organization is a small quantity generator not required to <br /> - - - ---- register--pursuant to Chapter 4. - - - <br /> PAYMENT <br /> Please complete the information below and mail with $77.00 fee to: RECEIVED <br /> San Joaquin County Environmental Health Department APP FEB 0 5 2014 <br /> NTY <br /> Medical Waste Management Program V I EWI�wWTAL <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 HEALTH DEPARTMENT <br /> Medical Waste Hauler Information <br /> ❑ New ❑ Renewal <br /> Medical Office/Business Name: 1 <br /> . /L� d� <br /> Medical Office/Business Address Iq ' <br /> City Sta Zip Code <br /> Contact Person: <br /> Phone Number: �► _ <br /> Storage Facility Name: <br /> Storage Facility Address: _ <br /> City e� 1 Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility dd/rresss: <br /> ity Code ?' <br /> State Yip <br /> List all employee na nd`tI e d5horized to transport the medical e I m <br /> was ore attach info): <br /> 1. Name: y'✓l Title: <br /> 2. Name: Title: - I <br /> 3. Name: e. Title: 41 5� <br /> A copy of this exemption and a tracking document shall beth emploe's possession ata'times while transporting medical waste. In addition,all copies of <br /> medical waste records shall a pt on file at neratoes or lth,care professional's facility. <br /> pp g / <br /> A licant Si na re: �' G %�'' _ te: <br /> Title: _ -G 1 <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: ,. — Date: per/—6/A <br /> Expiration Date:-It-/ 4.7 -i-Date Paid: l �~I Cash or heck :jr eceived By: <br /> EHD 45-015/2112 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />