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1MWU <br /> )NME 1N <br /> `5"" .E �o • SAN JOAQUIN COUNTY p �` <br /> ENVIRONMENTAL HEALTH DEPART E <br /> '. 600 East Main Street, Stockto 9 02- JAN 13 2012 <br /> (209)468-3420 Fax: (209) 464-0138 s /efd <br /> °q': -• �P t ENVIRONMENT HEALTH <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIONERMIT/SERVICE$ <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 /> Please complete the information below and mail with $77.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medlcal Waste Hauler Informatlon <br /> ❑ New L f enewal <br /> � . <br /> Medical Office/Business Name: AX 0 M,4-A P ci <br /> Medical Office/Business Address <br /> Contact Person: City Utate Zip Code <br /> Phone Number: <br /> Storage Facility Name: c --2 <br /> Storage Facility Address: r <br /> ity State Zip Coe 'o <br /> Permitted Treatment Facility Name: + �4t, +� � <br /> DermiHed Treatment Facility Address: <br /> City State Zip Code <br /> List all employee nam s and titles authorized to transport the medical waste (If more than 3, attach info): <br /> Name:1. T- _ -- ---- --- ---- <br /> 2. Name: �1'�ct7h�E7�>Ae ��,QA Title: VAI <br /> 3. Name: .I-.iANA GAZI(AZ ) Title: L_iJ/J <br /> A copy of this exemption aobe <br /> acking docAIIN <br /> umen hall be in a oy e's ossession a all times while transporting medical,waste. In ddition,all copies of <br /> medical waste records sheept file at on tor's or heal rep fessional' cility. <br /> Applicant Signature: z, Date: lQ <br /> Title: 04 1100 t Na <br /> DO NOT WRITE BELOW THIS LINE <br /> RENS Application Approval: Q,J, � (�J ,�� 1( ? Date: A-/fin/ /Z,, <br /> Expiration Date: `&/';� / tZ Date Paid: l / �� /O Z Cash or heck 2� ��ZReceived By: l <br /> EHD 45-0111/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION <br />