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' ^ <br /> SAN JOAQUIN COUNT <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 18O8East Hazelton Avenue, Stockton, CAS52O5-O232 <br /> (2O0)488-342OFmx: (2O9)484-0138Wmb:vmxmv.o]gov.org/ehd <br /> ro <br /> APPLICATION FORA 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 bemet: <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 ufthe 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 toregister pursuant hmChapter 4. <br /> 2. Information Document if the generator or parent organization is a small quantity generator not required to <br /> register pursuant toChapter 4. <br /> Please complete the information below and mail with $77'00 fee to: <br /> San Joaquin County Environmental Health Department <br /> yWodica|\�aoteW1onageman�Prognonn z�mu �� �� <br /> 18G8East Hazelton Avenue, Stockton, CAQ52O5-S232 <br /> MedIcal Waste Hauler Information <br /> New ~Renewal <br /> Medical Office/Business Name: GLEASON HOUSE <br /> K8edioo| OMice/BusinesoAddnesa 423 S. SAN JOAQUIN ST. <br /> STOCKTON, CA 95203 <br /> City State Zip Code <br /> Contact Person: KATHT.FFN MARSHALL <br /> Phone Number: (209) 373-2826 <br /> Storage Facility Name: HAMMER <br /> Storage Facility Address: 1721 E. HAMMER LANE, SUITE A STOCKTON, CA 95210 <br /> city State Zip Code <br /> Permitted Treatment Facility Name: STEDICYCLE <br /> Permitted Treatment Facility Address: 118/5 WHITE ROCK RD. <br /> RANCHO CORDOVA CA 95742 <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste than 3. attach info\: <br /> 1. Name: JUNJQLYN VED(AdlA Title: CLERICAL ASSISTANT <br /> 2. Name: DIANE FOUNTAIN Title: :ayu MANAGER <br /> 3. Name: BRANDON MICHELSON Tide: CHOW <br /> A copy of this exemption and a tr�cking document shall be In employee's possession at all times while transporting medical waste. /naddition,all copies m <br /> medical waste records sha <br /> Date:Applicant Signature: � <br /> Title: CE <br /> DO NOT WRITE BELOW THIS LINE <br /> REHSApplication Approval: Date: <br /> Expiration Date:N2, 10 Date Paid: Caaho :2)6/Z5_ Received By: <br /> EHD 45-011 5/2112 APPLICATION FOR ALIMITED QUANTITY HAULING EXEMPTION <br />