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-ftp oh 10 <br /> PQ��H SAN JOAQUIN COUNTY 77 <br /> o.,........ � ECEI!/ED <br /> -� ENVIRONMENTAL HEALTH DEPARTMENT DEC <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 2�1� <br /> • q ... (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd bAEN�RO�NME oDNTY <br /> <<soR HEALTH DEpARTN&A <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, 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 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 or a <br /> 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 to <br /> register pursuant to Chapter 4. <br /> Please complete the information below and mail with $77.00 fee to: <br /> San Joaquin County Environmental Health Department APPROVE <br /> Waste Management Program <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Medical Waste Hauler Information <br /> ❑ New Renewal <br /> Medical Office/Business Name: e- �,. �At— l9lJ <br /> Medical Office/Business Address Sly G/'Z Sty-el -W t't 2 " <br /> City State Zip Code <br /> Contact Person: �c� �", -S t, <br /> Phone Number: <br /> Storage Facility Name: M a1 vJ e') <br /> Storage Facility Address: ee, <br /> City State Zip Code <br /> g r <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: r oF IcL 6o RZ�. `f Of <br /> rfd�c j K °f6 3"3 <br /> City State Zip Code <br /> List all employee names and title authorized to transport the medical waste (If more than 3, attach info): <br /> 1. Name: Se-z &-ff tc ec( oz's 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 addition,all copies of <br /> medical waste records shall be kept on file at generator's or health care professional's facility. 1 <br /> Applica ty�igJ�atyre: Date: <br /> Title: (,dycc/ v <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: �\,�+� Date: j2V- %0/ <br /> Expiration Date: 12- /—�l /1 Date Paid: t�^/ ' /j3 Cash or Check#: ) ��- Received By: <br /> EHD 45-01512/12 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />