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oQ'aV .iik c SAN JOAQUIN COUNTY <br /> �.' •.o <br /> Q. •� ENVIRONMENTAL HEALTH DEPARTMENT JAN 1 0 2012 <br /> �« 600 East Main Street, Stockton, CA 95202-3029 <br /> (209)468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd ENVIRONMENT HEALTH <br /> PERMIT/SERVICES <br /> c,�oR <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 /> BILE U <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program t <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ❑ New enewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address <br /> Zc? <br /> City State Zip Code <br /> Contact Person: <br /> Phone Number: (� '250 9 6 <br /> Storage Facility Name: J `M fAw&6jU Al— <br /> Storage Facility Address: <br /> City I x-24 It-III State Zip Code <br /> Permitted Treatment Facility Name: `C C,t <br /> Permitted Treaiment 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: qCN-- Title: <br /> 2. Name. T Lklm Title: X6 2 <br /> 3. Name: Title: <br /> A copy of this exemption and a tracking Qcume t grls <br /> n employee's possession at all times while transporting medical waste. In addition,all copies of <br /> medical waste records shall be kept on fieralth care professional's facility. <br /> Applicant Signature: t ,a t ""ti Date: _ ` 2 t2— <br /> Title: d6iN&&Cr <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: Date: 01t /1� 1� <br /> Expiration Date: �1 13 I`I- Date Paid: l 1 )V 117- Cash or(D:��J�{1 Received By: i "" t <br /> EHD 45-0111129111 APPLICATION FOR A iMITED QUANTITY HAULING EXEMPTION <br />