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" ., AN JOAQUIN COUNTY100 <br /> '�� `t r + <br /> ENVIRONMENTAL.HEALTH DEPARTMENT L #VE:c. <br /> 600 East Main Street, Stockton,CA 95202-3029 Ju <br /> Telephoner(209)468-3420 Fax:(209)468-3433 Web:www.sjgd org/ehd ZO,Q <br /> SAN IOAQUIN CCU <br /> APPLICATION A LIMIT TIT HAULING E MPT IRCN�EN-VANS <br /> H c�EPARTMENr <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, 00 __ _ <br /> is i'�:_7 s1C0 <br /> Please complete the information below and mail with$77.00 fee to: 3 4L F Eif\JANCIAL SEWICES <br /> San Joaquin County Environmental Health Department �- <br /> Medical Waste Management Program L �-5q <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> p'New ❑ Renewal _ <br /> Medical Office/Business Name: d1►" 1�� <br /> 1'.�I � ( I ►" Com " <br /> Medical Office/Business Address: <br /> -- S�- <br /> State Zip Code <br /> Contact Person: -/ <5 <br /> Phone Number: 96}q_ <br /> Storage Facility Name: , l <br /> Storage Facility Address: 5 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: 11 ®' e • <br /> Permitted Treatment Facility Address: <br /> -5�PC46N 0- <br /> City State Zip Code <br /> List all employee name, and titles authorized to transport the medical waste(If more than 3, attach info): <br /> 1.Name: fid Title: <br /> 2.Name: G- Title: <br /> 3. Name: t.% Title: <br /> p g f�m 3 n s f a`v <br /> A copy of this exemption and a trackin do ument shall be in em In se's ossession a times w ii t n ortmg me Cal roasts. In <br /> addition,all copies of meds l vaste records shall be kept on file at 8eneratoes or health care professional's f//aci''li(r}y. <br /> Applicant mature Date: 1 <br /> T. <br /> Title: v'/"T , ''1 <br /> DO NO W?,ITE BELOWIS LIN9 <br /> R.E.H.S. Application Approval: . Date: / / <br /> Expiration Date: / / Date Paid: / / ( C Check#: 1 Received Ey: J _- <br /> FHD 45-01 -7. C, <br /> 111191108 <br />