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SAN JOAQUIN COUNTY RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> `•how : 600 East Main Street, Stockton,CA 95202-3029 APR 2 7 Zn1� <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:w\vw.sjgov.org/ehd <br /> ENVIRONMENTAL HEALTH <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIONPERMIT/SERVICES <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. D W O o %11139 <br /> Please complete the information below and mail with$77.08 fea:to: 00 � <br /> San Joaquin County Environmental Health Department b 3 143 <br /> g <br /> Medical Waste Management Program O 5 3 to 21 1- <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Medical Waste Hauler Information <br /> j New ❑ Renewal 011TiPonni <br /> Medical Office/Business Name: <br /> � b j JI <br /> Medical Office/Business Address: t <br /> S <br /> City - 1 o P)Y"\ Stat Zip Code <br /> Contact Person: 01 L(I Y\Y�c <br /> Phone Number: - s <br /> Storage Facility Name: WAk 1 k c�c- S:�s ►� — !f1 alo;l e t��"tea <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: t <br /> Permitted Treatment Facility Address: <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: -See CLI 1CtZrW( 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 Sign re:��71 DDate: <br /> ck/s— <br /> Title: C/)1C7S.L <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: f� t Date: <br /> Expiration Date: / /�_Date Paid: Lk /I e*A. .Check#: yk.Aq Received By:_ t-57 <br /> EHD 45-01 <br /> 11/19%08 <br />