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oFn4ty;`., <br /> �� IN <br /> .�•-..�.�,z SAN JO AQU COUNT <br /> ]ENVIRONMENTAL 14EALT11 DEPARTMENT <br /> ��.- 600 East Main Street, Stockton,CA 95202-3029 <br /> r'elephOne:(209)468-3420 Fax. (209)468-3433 Web:www.sjgov.org/ehd <br /> a,. <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management conditions must be met: g ent Act",the following <br /> The generator or health care professional generates less than 20 <br /> pounds of medical waste per week,transport lass <br /> than 20 pounds of medical waste at any one time,,maintains a tracking <br /> generator or parent organization has on file one of the following: document pursuant to Chapter 6 and the <br /> !• Medical Waste Adranagement Plan if the generator or parent organization is a large Or a ental]quantity <br /> q ty generator required to register pursuant to Chapter 4. quantity generator ;;;, <br /> 2. lnformatton Ducume y g <br /> nr if the generator or parent organization is a small quantity generator not required <br /> to register pursuant to Chapter 4, <br /> i l <br /> Please complete the <br /> information below and moil with$77.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management program <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Medical Waste Mauler Information <br /> d New <br /> XRenewal <br /> Medical!office/Business Name: Stockton Unified School District <br /> '4edical Office/13usiness Address: <br /> 701 N. Madison Street <br /> St C11toon, CA 9 20 <br /> Contact Person: City State <br /> Phone Nwnber: Tama Evans,• Administrator Gip Code <br /> 209.933.7060 ---------- 3 <br /> Storage Facility Addreddress <br /> Storage Facility s Stockton Vnified School District Health Services <br /> : 1144 E. Channel Street <br /> Stoc to A 0.5 <br /> City State <br /> Permitted Treatment paeility Name: Steric cIe, Inc, zip Code <br /> Permitted 1'reatment Facility Address: <br /> 1. <br /> C41 3 <br /> Fresno CA 93722 <br /> City State 77 <br /> List all employee nam,s and titles authorize Lip Code <br /> 1. Name: �� <br /> transport the medical waste(If more than 3,attach info): <br /> 2. Name: Title: <br /> 3. Narne, Title: <br /> Title: <br /> A copy of this exemption and a tracking document shall be,u employee's posaessivn at all times while transporting medical waste. Tn <br /> addition,all copies of medical waste records shall be kept on file tt generator's or health etre s While <br /> trans porting. <br /> Applicant Signature: <br /> _Title: Administrator of Health Services Date: 5/25/11 <br /> DO NOT WRITE BELOW TIJIS LINE <br /> R.E.H.S. Application Approval. <br /> Expiration Date: Date: 2� <br /> — /�/_Zllate Paid: /�L//Z Cash Check# N d � r <br /> EHD 45-01 47 Received By: 2�� <br /> E0/E0 39Vd S30IAN3S Hi-V3H QSf1S T90LCE660Z 0tt1:91 ZTOZ/LZ/Z0 <br />