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E GOP ; <br /> SAN JOAQUIN COUNTY ,. <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 � <br /> Telephone. 209 468-3420 Fax: 209 468-3433 Web:www.s ov.or eIld(�( �4t1,SAr <br /> P ( ) ( ) Jg g/ ',, r, <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEM f <br /> 142010 <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Nffi nt Act",the following <br /> conditions must be met: PERM�SER y�L� <br /> The generator or health care professional generates less than 20 pounds of medical waste per wee��'sp6rt 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 <br /> or a 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 <br /> to register pursuant to Chapter 4. pW DUI I q-03 <br /> Please complete the information below and mail with $77.00 fee to: �b <br /> San Joaquin County Environmental Health Department A(L,70 3.7 S�J <br /> Medical Waste Management Program ,p[Z-0.53SV)2 <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Medical Waste Hauler Information <br /> New ❑ Renewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: <br /> city State _ Zip Code <br /> Contact Person: ( a"Lief)e &i:k4__(-7ZUw/ <br /> Phone Number: .209— 5 k ' 3 S <br /> Storage Facility Name: x/17/ 7/f " /te Z/)C - <br /> Storage Facility Address: y�lP .IU PrP S 14 /7 704 F-0,1 AeL- <br /> /Lld Ly c�S to 01- <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Sky,Ct C%C'.- _ <br /> Permitted Treatment Facility Address: 35 - 6kj <br /> Fres ho r14 <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:J10 `yl!�alhegl Title: <br /> 2.Name: Title: <br /> 3.Name: Title: <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical wa to records shall be kept on file at generator's or health care professional's facility. <br /> Applicant ignature: �1 �C '�c��i.0 �' Date: /2- -/6, <br /> Title: X 161/Clz/ GLC�CIIi/Xriy' <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: q k -- Date: 12/2 //b <br /> Expiration Date: 1#1/_6L/1 Date Paid: Va / A 4/ 10 Gash-or-Check#: 3 4 q�-k q Received By: <br /> EHD 45-01 <br /> 11/19/08 <br />