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TV 1"n <br /> R- --�► <br /> �p�gurN c•G 1112 dimial <br /> SAN ..JOAQUIN COUNTY PAYMENT <br /> �.• , '.o <br /> N:_ t <br /> ENVIRONMENTAL HEALTH DEPARTMENT RECEIVED <br /> • 1868 East Hazelton Avenue, Stockton, CA 95205-6232 NOV 27 2013 <br /> (209)468-3420 Fax: (209) 464-0138 Web:www.sjgov.org/ehd <br /> SAN JOAQLiIN COUNTY <br /> EWR <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> HEEALTH DEPARTTMAENT <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 /> A,7!7w <br /> R <br /> San Joaquin County Environmental Health Department Medical Waste Management Program 06,;26'1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Medical Waste Hauler Information <br /> ❑ New 01IRenewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address <br /> city tat Zip Code <br /> Contact Person: <br /> Phone Number: G <br /> Storage Facility Name: �� <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: <br /> City State zip Code <br /> List all employee names and titlep authorized to transport the medical waste (if more than 3, attach info): <br /> 1. dame: Gt- zeCC Title: _A :D1 <br /> 2. Name: s� c' S'� Title: AA*- <br /> 3. Name: 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 addition,all copies of <br /> medical waste records shall be kept on filer at goneratorRor health care professional's facility. <br /> Applicant Signature: Tti Date: ` <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: Date: 21-111, 1L'/� <br /> Expiration Date: tL IDate Paid. 1 _LI�I 13 Cash or Check#: Received By: t16 <br /> EHD 45-01512/12 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />