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SAN JOAQUIN COU �+ <br /> PAY4EN <br />'E •_ .o RjE�ErvE <br /> COUNTY ' D <br /> +� ENVIRONMENTAL HEALTH DEPARTMENTAL 2 2Q14 <br /> SAN jo <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 -h-0AOUA,cou <br /> (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd �'}'°N�;IAT <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 /> I. 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 genera r of required to <br /> register pursuant to Chapter 4__, <br /> S <br /> Please complete the information below and mail with $77.00 fee to: U:S.Healthwork-s Inc. <br /> San Joaquin County Environmental Health Department Tax Department � <br /> Medical Waste Management Program 125124 Springfield Court,Suite 2'00 <br /> 9868 East Hazelton Avenue, Stockton, CA 95205-6232 Valencia, CA 91355-1098- — J <br /> Medical Waste' Hauler Information <br /> ❑ New Akehewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address (� Y SIC• <br /> Cit <br /> Contact Person: _ y state Zip Code. <br /> f Phone Number: <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> Ciittyr State Zip Code <br /> Permitted Treatment Facility Name: 7TCJY`��j� <br /> Permitted <br /> 7_.,� -T-reatr-rient-Facility Address:°= <br /> City State Zip Code <br /> List all employee narlies,and tit esputhorized to transport the medical waste f more than 3, attach info): <br /> 1. Name: Title: y <br /> 2. Name: k ,. C'A Title: <br /> 3. Name: G Title: <br /> fA copy of this exemption and a tracking document shall ba In employee's possession at all times while transporting medical waste, In addition,ail copies of <br /> medical waste records shall be kept on file at generators or health care professional's facillfy. <br /> Applicant Si n Pure: Date: <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: -- Date: 1111 <br /> I Expiration Date: fz 131 l—A-Date Paid: /2--/ 6L 13 Cash onjire : 7�3�� Received By: <br /> f EHD 45-01512/12 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />