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An. 25. 2013 3: 39PM San Joaquin County No. 0443 P. 2 <br /> Cku <br /> SAN JOAQUIN COUNTY <br /> N 2 9 2013 ENVIRONMENTAL HEALTH DEPARTMENT <br /> m:. <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> RONMENTAL F.,EALT'q09)468-3420 Fax: (209)464-0138 Web,www,sjgov.org/ehd . <br /> PER UiITISAPPLICATION 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 /> RF�ME�►T <br /> Please complete the information below and mail with $77.00 fee to., 6' v V <br /> San Joaquin County Environmental Health Department APPROVESq JAN 292013 <br /> Medical Waste Management Program NJpq <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 FIF vV/ROMN COUN <br /> ry <br /> Medical Waste Hauler Information MCEPA TMFM, <br /> ❑ New 191 Renewal <br /> Medical Office/Business Name: Stockton Unified School District <br /> Medical Office/Business Address , 701 North Madison Street <br /> Stockton, CA 95202 <br /> City State Zip Code <br /> Contact Person: Tammy Evans, .Administrator <br /> Phone Number: 209.933.7060 <br /> Storage Facility Name: Stockton Unified School District — Health Servings <br /> Storage Facility Address: 975 North D Street Stockton, CA 95205 <br /> City State zip Code <br /> Permitted Treatment Facility Name: Stericycle, Inc. <br /> Permitted Treatment Facility Address: 4135 West Swift <br /> Fresno . CA 93722 <br /> City State Zip Code <br /> List all employee names and titles authorized t trans ort the medical waste(If more than 3, attach info): <br /> 1. Name: ' �S[?. See cc- ClGl'r-� �i Title: <br /> 2. Name: Title: <br /> 3. Name: Title: <br /> A copy of thls exemption and a tracking document shall be in employee's possession at all times whlle transporting medical waste. In additlon,all coples of <br /> medical waste records sh lb ept on file at generators or health care profasslonal's facility. <br /> Applicant Signature: Date: 12/3/12 <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: c� L.._. Date: �/30/� <br /> Expiration Date:�/�/�Date Paid: � 12 /113 Cash or Check l#:;Z 5 1 66 Received By: <br /> EHD 45-016012 APPLICATION FORA LJMITED QUANTITY HAULING EXEMPTION <br />