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I Nom. <br /> SAN JOAQUIN COUNTY Rr� d E <br /> ei µ I <br /> ENVIRONMENTAL HEALTH DEPARTMENT vE <br /> i,i 600 East Main Street, Stockton, CA 95202-3029 OCT _Z Zoll <br /> r > ► Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br /> r 'ciuS'' SAN Jp� <br /> E CJUIry CpUN <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPT161/o�qR M1JNr <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 $77.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program Rob 0 O `I - 1 tt�3,� <br /> s <br /> 600 East Main Street, Stockton, CA 95202-3029 p <br /> Medical Waste Hauler Information <br /> XN <br /> New F1 Renewal <br /> Medical Office/Business Name: Ik USD <br /> Medical Office/Business Address: �b (>' 14 n C ac i R <br /> City State Zip Code <br /> Contact Person: l Ccs O <br /> Phone Number: a ' h 6C�A- O S(:k <br /> Storage Facility Name: P,i Ppn A S thou I <br /> Storage Facility Address: 1 -v l S D r( 0 <br /> 1pDy-) C /A— gld6� n to <br /> City State Zip Code <br /> Permitted Treatment Facility Name: `:� r"j Cu 0`Q . <br /> Permitted Treatment Facility Address: IV) <br /> 5 <br /> 1 1) a� <br /> LIl �N 1-pY rt �� (4 61 <br /> City tate Zip Code <br /> List all employee names and titles authorized to transport the medical waste (If more than 3, attach info): <br /> 1 . Name: �UL Gl Qllc( erS on P iu Title: ,C n h o u l I`(t r V.(4 <br /> 2. Name: /YI'1 (rA L ))n Title: <br /> 3 . Name: ( nfji s<A SAI-Ws ,L' l✓ 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: i , �__ Date: _tel //_�. � j / n <br /> Title : A? ti o G 1 <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H. S . Application Approval: - �c��A ti..Ul•.1.I1 Date: 14—/ IL <br /> Expiration Date: tv !&3 1 / 10 Date Paid: I W 113 I d Cash or hecReceived By: <br /> EHD 45-01 <br /> 11/19/08 <br />