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SAN JOAQUIN COUNTY A 0a49foZC,, � <br /> ox <br /> ENVIRONMENTAL HEALTH DEPARTMENTgs ( 7 <br /> 600 East Main Street, Stockton,CA 95202-3029 7 aZ D <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: i <br /> 1. Medical Waste Management Plan if the generator or parent organization is a large quantity generator i <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 /> r. <br /> to register pursuant to Chapter 4. <br /> Please complete the information below and mail with $77.00 fee to: PAYME <br /> Nr <br /> San Joaquin County Environmental Health Department RECEiV D <br /> Medical Waste Management Program JUL 14 2011 <br /> 600 East Main Street, Stockton, CA 95202-3029 SAN JOAQUIN NM cpu <br /> Medical Waste Hauler Information ��N��0FP T <br /> New F1 Renewal ' <br /> Medical Office/Business Name: !C -L' — �C u NL- '�2� C� <br /> Medical Office/Business Address: _AM P7�CZA C - ST- <br /> 1:2 <br /> T— <br /> � r A °l S�Z 2- ' <br /> City State Zip Code <br /> Contact Person: = - <br /> Phone Number: ICTC04 S <br /> Storage Facility Name: S. ��/�►M�i c� M,= I]Oj <br /> Storage Facility Address: 100 Lv� i <br /> z9 5 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: S 1 alk e-tl <br /> Permitted Treatment Facility Address: 'G'JZ� <br /> City ._ � State <br /> ,J' 1 Zip Code <br /> List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): r <br /> �.Name: G M Title: r'S i <br /> Z.Name: Title: /1r4� <br /> 3. N oemC ram, t 4. <br /> A copy of this exemption and a tracki d r c t all be in employee's possession at all times while transporting medical waste, In <br /> addition,all copies of media]waste cor s shal e, ept on rile at generator's or healthcare professional's facility. <br /> 'Applicant Signature: Date: <br /> Title: <br /> D OT. WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: _Date: <br /> Expiration Date: I�Date Paid:�I��l�_Cash or Check#: �k t J Received By: <br /> ERn 45.01 <br /> ivi9�os <br />