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SAN JOAQUIN COUNTY <br /> y X ENVIRONMENTAL HEALTH DEPARTMENT <br /> '• 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> cq •:..:.... (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> so <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 /> register pursuant to Chapter 4. PAYMENT <br /> Please complete the information below and mail with $77.00 fee to: RECEIVED <br /> San Joaquin County Environmental Health DepartmentO'`JEj D DEC 0 3 2013 <br /> Medical Waste Management Program APy�P R SAN.IOAQUIN COUNTY <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> Medical Waste Hauler Information <br /> ❑ New renewal <br /> Medical Office/Business Name: � Yll i( v1C�� 1r1C <br /> Medical Office/Business Address 610 . tv <br /> AV,n / <br /> City I 1 State Zip Code <br /> Contact Person: o unr AM- <br /> Phone Number: "I - 51 W314 S ffAl <br /> Storage Facility Name: lt', (1V)Q111Ci <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: CA-c-, <br /> Permitted Treatment Facility Address: R-A <br /> city State Zip Code <br /> List all employee names,and titles authorized to transport the medic alw to (If more than 3, attach info): <br /> 1. Name: Tit le: �1 Y ,P Q KZ <br /> 2. Name: Title: 0Q SU 91 Y- DR3 <br /> 3. Name: I ' Title: Vj1j CAV, MOMQCK <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. in addition,all copies of <br /> medical waste records shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signat re: Date: Z 13 <br /> Title: ZO N <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: _ - �`'z u���-- Date: <br /> Expiration Date: 12 / 3\ /1 I Date Paid:�/� / Cash o he -. 1 gg0 Received By: _ <br /> EHD 45-01512112 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />