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. s • <br /> �°Pp.. .E'•�o SAN .IOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT JI` j w 4 2012 <br /> Q. a <br /> W < <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> ENVIRONMENT HEALTH <br /> (209)468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd PERMIT/SERVICES <br /> 4<<F o RNA <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. <br /> Please complete the information below and mail with $77.00 fee to: rn n P y <br /> FILE UU, <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 /> ❑ New Renewal <br /> Medical Office/Business Name: ,vX't <br /> Medical Office/Business Address lbq N• / ru C> S4- <br /> City State Zip Code <br /> Contact Person: L- Cc 9-1 <br /> Phone Number: _'407 — _ yp <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: <br /> Pefroitted Treatm ant Facility AddresS: <br /> City State -Zip Code <br /> List all employee names and titles authorized to transport the medical was (If more than 3, attach info): <br /> 1. Name: (e_a lie 4"tN Title: <br /> 2. Name: `)ate S;w\l Q-V) Title: tj <br /> 3. Name: AI,'S LcA &o N-4c,1e-16 Title: _�10 <br /> A copy of this exemption and a trackin ent shall bei employee's possession at all times while transporting medical waste. In addition,all copies of <br /> medical waste records shall be k p o file at generators ealth care professional's facility. / <br /> Applican Signature: Date: 3 ,2o II, <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: Date: 40�/�Z� <br /> Expiration Date: 1Z 1-7j / 12 Date Paid: � / 121 11'Cash orheck :_ W Received By: <br /> EHD 45-0111/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION <br />