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SAN JOAQUIN (_OUNTY <br /> ILEONMENTAL HEALTH DEPART T RECD ENT' <br /> 1 <br /> - ast Main Street Stockton CA 95202-30 <br /> VE[) <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web: www.sjgov.org/ehd JAN 2 7 2011 <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIOEIENv pALTH 04 ENTAL <br /> ARTME T <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. <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 /> Medical Waste Hauler Information <br /> ❑ New Renewal <br /> Medical Office/Business Name: a ' � &✓5//IL " <br /> Medical Office/Business Address: 131J k45rloly"l VE <br /> '/A 11.t7a9s35 <br /> City A State Zip Code <br /> Contact Person: (yI`J?G 11S <br /> Phone Number: <br /> Storage Facility Name: if C[ OLi� Sf c� <br /> Storage Facility Address: 11 47- AQWell qVe <br /> S3 74, <br /> City State Zip Code <br /> Permitted Treatment Facility Name: 1 ` <br /> Permitted Treatment Facility Address: / "5` 1� ro2 <br /> FAMlw <br /> City State Zip Code <br /> List all employy—eAemets a�autFi'orized to transport the medical waste (If more than 3, attach info): <br /> 1. Name: GI / Title: <br /> 2. Name: Co i I Title: <br /> 3. Name: Title: ld tr'e h ���. I�i► i' eK <br /> A copy of this exemptidh and a trac ing documen�l �6e in employee's possession at al,011C hil porting medical waste. In <br /> addition,all copies of medic waste records shall be kept on file at generator's or health care professional's fac" ity. <br /> Applicant ature Date: S <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: ��„��--�� tz:L�9.k. Date: <br /> Expiration Date: Date Paid: C-a4i-ar Check#:j 222E,� Received By: <br /> EHD 45-01 <br />