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SAN JOAQUIN COUNTY C �! g <br /> ENVIRONMENTAL HEALTH DEPARTMENT 6v)v ZZ$q7 <br /> •. .:- t �:- 1868 East Hazelton Avenue, Stockton, CA 95205-6232 ,�3r-l–r� <br /> Via= �P Telephone:(209)468-3420 Fax:(209)468-3433'W,eb:www.sjgov.org/ehd <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: <br /> g <br /> f 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 require <br /> to register pursuant to Chapter 4. <br /> Please complete the information below and mail with$77.00 fee to: PAYMENT <br /> RECEIVED <br /> San Joaquin County Environmental Health Department "PR. Y JULa 2 Q3 <br /> Medical Waste Management Program YJ -Al l <br /> 1868 E.Hazelton Avenue, Stockton, CA 95205-6232SAN JOAQUIN COUNTY <br /> ENV,IF30MENTAL <br /> Medical Waste Hauler Information .7HtALTHbEPANTMENT <br /> Lt�'New ❑ Renewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: <br /> City State Zip Code <br /> Contact Person: <br /> Phone Number: qb <br /> Storage Facility Name: <br /> Storage Facility Address: 1 �n ' <br /> City State Zip Code <br /> Permitted Treatment Facility Name: 7 <br /> Permitted Treatment 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: Title: R—W <br /> 2.Name: �7 Title: <br /> 3.Name: Title: l� <br /> '--st�, r 6- <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 Si nature: 11�`. Date: _ L 5 12-0) <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: _ , - _ Date: 611L1ls– <br /> Expiration Date: 11 Date Paid: �I I/ Cash or Check#: 1074 Received By: <br /> EHn 4s-o1 <br /> un9M <br />