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SAN JOAQUIN COUNTY PAt1Er N-1- <br /> RECEIVED <br /> - ENVIRONMENTAL HEALTH DEPARTMENT i <br /> N ^X <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 JA 2013 <br /> 6A14 C <br /> •�A��FORa`P (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd °R.o;kE <br /> HEALTH DE?QRT EN7 <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 healthcare 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 /> register pursuant to Chapter 4. — - - -- -- ----_.y---- --- _--- <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 /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Medical Waste Hauler Information <br /> 0 New Renewal <br /> Medical OfficelBusiness Name: � •�,� �, <br /> �/y ✓ <br /> Medical Office/Business AddressS <br /> City State Zip Code <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: rr,4P✓ Cb✓AIP In, Title: Vswhile <br /> 2. Name: s^,s5� � 1Title.3. Name: Title:A copy of this exemption and a tracking documen II be In a plo ee's possession atnsporting medical waste. In addition,all copies of <br /> medical waste records shall be kept on file atgdnerafoN or althessional's facility.Applicant i ature: Date: 1,a" <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: -ac A®,,, Date: 6 v 4 <br /> Expiration Date: / / Date Paid: ! / 43 Cash or ec 6,6Received By: <br /> EHD 45-01 5/2/12 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />