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oARu�N # SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <br /> A�1 FORS` <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 /> resister Dursuant to Chapter 4. <br /> Please complete the information below and mail with $77.00 fee to: PAYMENT 9--) <br /> RECEIVED <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program FEB 16 2012 <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> Medical Waste Hauler Information HEALTH DEPARTMENT <br /> ❑ New C�tenewal <br /> Medical Office/Business Name: 0 6 464 l r,5' <br /> Medical Office/Business Address _r 014ramd& 1i <br /> If. O <br /> Cit State Zip Code <br /> Contact Person: _)_x10 <br /> Phone Number: <br /> Storage Facility Name: 2, to- CJ !/ <br /> Storage Facility Address: <br /> City f State Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facilitv Address: �_ !v_� <br /> City State Zip Code <br /> List all employee narrg�es ad titles authorized to transport the medical wast (If more than 3, attach info): <br /> 1. Name: Cr Title: <br /> 2. Name: 3TA4vmxerud Title: <br /> 3. Name: P Title: N <br /> A copy of this exemption and a tracking docume s 1 i employee's possession at all times while transporting medical waste. In addition,all copies of <br /> medical waste records shall be on e e ato o health care professional's facility. <br /> Applicant Signature: Date: <br /> Title: <br /> ((�� <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval:,,'Q_ �cAA-.. Date: sLZ�29_13.- <br /> Expiration Date: Uate Paid: / t,2-Cash or Check#: Received By: <br /> EHD 45-0111/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION <br />