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E-,011S <br /> SAN JOAQUIN COUNTY WED <br /> A <br /> ENVIRONMENTAL HEALTH DEPARTT ll li <br /> 600 East Main Street <br /> Stockton,CA 95202-3029 JUL 1 5 �UIO <br /> Telephone. (209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> ENVIRUNIVIENT HEALTH <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTicKRMIT/SERVICES <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management Act",the following <br /> conditions must be met: ds of medical waste per week,transport less <br /> The generator or health care professional generates less than 20 poun <br /> maintains a tracking document pursuant to Chapter 6 and the <br /> than 20 pounds of medical waste at any one time,mai <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 /> 9,New F1 Renewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: <br /> State zip Code <br /> city <br /> Contact Person: <br /> Phone Number: <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: <br /> city State Zip Code <br /> List all employee names and titles authorized to transport the medical waste*(If more than 3,attach info): <br /> 1.Name: Title: <br /> Title: 4-\"v <br /> 2.Name: <br /> 3.Name: Title: <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical washrecords shall be kept on file at generator's or health care professional's facility. <br /> Applicant Sign tures <br /> Date: <br /> Title: <br /> Do NOT WRITE BELOW THIS LINE Date: <br /> R.E.H.S. Application Approval: <br /> Expiration Date: _/—/—Date Paid: —/—/—Cash or Check#: Received By: <br /> FED 45-01 <br /> 11,19M <br />