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j3p/H�tiN R-1 SAN JOAQUIN COUNTY <br /> l� ti <br /> EMRONMENTAL HEALTH DEPARTIVOT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone: 209 468-3420 Fax: 209 468-3433 Web:www.sjgov.org/chd <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. rA 010/1-7-11 <br /> Please complete the information below and mail with $77.00 fee to: A4 ")433 ppAAF ET <br /> REC D <br /> San Joaquin County Environmental Health Department .2p1� <br /> Medical Waste Management Program SUN 1 <br /> 600 East Main Street, Stockton, CA 95202-3029 �N COUNTY <br /> Medical Waste Hauler Information saOA R MENTMENT <br /> HEALON DEpppR <br /> M New ❑ Renewal <br /> Medical Office/Business Name: CTTI up IaZF 1)E'PA`P-"Pl <br /> Medical Office/Business Address: 1 Z TP PA U SOP TEQ <br /> y\-Tynj C,+1-) Cl 5 21 D <br /> City State Zip Code <br /> Contact Person: L---r-c-xja Aftj—i '50-g- V\A, MER` -S <br /> Phone Number: pl(�',- 1)3"1"i377 <br /> Storage Facility Name: C7---rt C)V- �dL`�1C pC�LCE bepiT RT-Wtt� <br /> Storage.Facility Address: -0A E l3 ST <br /> 'trzc Ti w Gq Y320 2 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: r G <br /> Permitted Treatment Facility Address: ra -sar ►`-FI- Air, <br /> doe 3 22.E G Z3 <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:LTA-o QbePsV£- CLPCXv Title: <br /> 2.Name:b- A&)L.EY SITU-ALD Title: <br /> 3.Name:&56-( PEEP 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 w ste records shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: C Date: Sb 1 / <br /> Title: I.Z'EU-r&-ry n <br /> DO NOT WR TEBELOW THIS LINE <br /> R.E.H.S. Application Approval: C/ p Date: <br /> Expiration Date: Date Paid: Cash Check Received By: <br /> EHD 45-01 <br /> 11/19/08 <br />