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SAN JOAQUIN COUNTY <br /> a a ENVIRONMENTAL HEALTH DEPARTMEI T <br /> 304 East Weber Avenue, 3'd Floor,Stockton,CA 95202-2708 <br /> P (209)468-3420-Fax:(209)468-3433 - Web:www.co.san-joaquin.ca.us/ehd <br /> �tFORa` <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,transport 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. <br /> Please complete the information below and mail with$70.00 fee to: <br /> San Joaquin County Environmental Heaiih Depal«-nent <br /> Medical Waste Management Program PAYMENTRECEIVED <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 <br /> Medical Waste Hauler Information DEC 32003 <br /> ❑New ®Renewal SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> Medical Office/Business Name: Hospice of San Joaquin <br /> Medical Office/Business Address: 2609 E Hammer Lane <br /> Stockton CA 95210 <br /> City State Zip Code <br /> Contact Person: Donald E Gallup <br /> Phone Number: (209) 957-3888 <br /> Storage Facility Name: Pharmacy Care Concepts <br /> Storage Facility Address: 7720 N Lorraine Avenue <br /> Stockton CA 95210 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Pesco Drug Disposal <br /> Permitted Treatment Facility Address: P 0 Box 231037 <br /> Sacramento CA 95863 <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste(Ifmore than 3,attach info): <br /> 1.Name: Please see attached 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 waste records shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: (A Date: 11/26/03 <br /> Title: 0 erati o s Coordi na r <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: <br /> Expiration Date: / / Date Paid: l c�/b_3/,9 Cash or(�#:Al Received By: <br /> EHD 45-02-001 <br /> 10/7/2003 <br />