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j • SAN JOAQUIN COUNTY PAYMENT <br /> ENVIRONMENTAL HEALTH DEPARTMENT RECEIVED <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd JUL _ 7 2010 <br /> �7>' <br /> SANNVI RONMENTAI- <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIONH�n-i EDN" ' <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. 6A DCC;L04 Lj,S-. <br /> Please complete the information below and mail with$77.00 fee to: (LDD31.513 <br /> San Joaquin County Environmental Health Department Q c-: L�55 7 <br /> Medical Waste Management Program I g_o <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ..New ❑ Renewal <br /> Medical Office/Business Name: �,v��;r; U C,ire_ S�rvr Ce-S, <br /> Medical Office/Business Address: t oil 65 rj el *t-L- <br /> City State Zip Code <br /> Contact Person: rcc-c- >4 C <br /> Phone Number: �-ye-i c e4l <br /> Storage Facility Name: CAka, 5.��rc�-� �stc--• <br /> Storage Facility Address: t'O•k� tom, rz.` �rz.,clw Ste. la f4o' <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Sktv-� c-k-t-- 1:4, . <br /> Permitted Treatment Facility Address: �t- �l ii✓� <br /> o - G <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: <br /> ,all G /���G� Title: <br /> 2.Name: Title: <br /> 3.Name: 24/e-r 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 wast records shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signtures —= -� Date: <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: - � ►- Date: -7 <br /> Expiration Date: 12 / _/ IIC� Date Paid:�/ / I O C Check#: a9 Received By: � <br /> EHD 45-01 <br /> 11/19/08 <br />