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��m ����0ly� ��0��� <br /> ��,, ., ,,.~ <br /> ����l�0�JK0E��A� ������� ������TKUE�T <br /> � . . � � � �� <br /> ��� <br /> 188OEast Hazelton/�^anue. Stockton, CA85205-8232 « � 4u1� <br /> (2O9)4G8-342UFm�: (2OQ\404-0138VVmb: vmww� govorg/ehd '�. _^`^n"� <br /> cowily <br /> ^,_ xcAox6EPkRTMZVr <br /> �� <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 bamet: <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 orparent organization has onfile one ofthe following: <br /> 1. Medkca/N/aobmManogeonentPlanifthegenenohororpnrentorgnnizationisa |argaquenUtygenerohorora <br /> small quantity generator required toregister pursuant tnChapter 4. <br /> 2. Information Document if the generator or parent organization is a small quantity generator not required to <br /> register pursuant hzChapter 4. <br /> Please complete the information below d mail with $77.00 fee t <br /> San Joaquin County Environmental Health Department APPROV <br /> Medical Waste Management Program I 1� I <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Medical Waste Haule Information <br /> 0 New Renewal $ <br /> Medical Office/Business Name: )fVA4L"�� <br /> Medical Office/Business Address i9w 6- alo." <br /> City State Zip Code <br /> Phone Number: <br /> ` <br /> Storage Facility Name: <br /> Storage Facility Address: /- <br /> Permitted Treatment Facility Name: <br /> Pnrm|ttedTreatment FaoSityAddress: <br /> City State Zlp'Gode <br /> List all employee names medical h 3attach info): <br /> 1� Name: <br /> 2. Name: Title: <br /> 3. Name: Title: <br /> A copy of this exemption and a tracking documentAhall be in employee's possession at all times while transporting medical waste. In addition,all copies m <br /> medical waste records shaill be kept n fi at g��professional's facility. <br /> Applicant Signature: Ooho: Id <br /> Title: <br /> 0O NOT WRITE BELOW THIS LINE <br /> REH8AocJ�o�onAopmva|: Date: ��/��-8[�� <br /> Expiration Date: Date Paid: 1-2-1 /^Y Cash urCheck#: 3043 Received By: <br /> c*o45-01 5121l APPLICATION FOR ALIMITED QUANTITY HAULING EXEMPTION <br />