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PAYMENT <br /> I <br /> SAN .1fv7AQUINCOUNTY REC <br /> •,.., a <br /> D <br /> ENVIRONMENTAL. HEALTH DEPARTMENT DEC 16 2011 <br /> .. ;_ <br /> F. 600 East Main Street, Stockton, CA 95202-3029 SAN Jp <br /> UIN <br /> (209)468-3420 Fax: (209)464-0138 Web:www.sigov.org/eh.d .. ENVIRO ME COUNTY <br /> ¢CfFp� •. NEA1 Ty f)EpARTAL <br /> 'APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for "Limited Quantity Hauling'Exemption" pursuant to the"Medical Waste Management Act", the following <br /> conditions most be met: <br /> The generator or health tare 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: FILE <br /> San Joaquin County Environmental Health Department C <br /> Medical Waste Management Program <br /> 600-East-Main Street;Stock-ton, CA 952-O'1_-3p2g - <br /> Medical Waste Hauler Informatlon <br /> 0 New )(Renewal <br /> 1 <br /> Medical Office/Business Name: �St A'ls ( tu eplfc r <br /> Medical OfficelBuslness'Address o►. Stf-ems <br /> City 9� stale Zip Code <br /> Contact Person: M1 <br /> Phone Number. - [ <br /> Storage Facility Name: 3L. IDW-" M jl ' �n*y_ <br /> Storage Facility Address: P S <br /> City rState� Zip dbde, I <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility'Address: P <br /> r N I <br /> City State Zip Code <br /> List all employee nam s and fitler*2juthorized to tr sport the medical waste(If more than 3, attach info): <br /> i 1. Name: Title: <br /> 2. Name: Title: <br /> 3. Name-, Title: <br /> A COPY of this'exemption and a trackingocument aha In employee's possession at all times whlle transporting madicat waste. In addllton,all coples of <br /> medical waste records shall be kept o t gone r or hoaith care profossionars facility, I <br /> Applican Signatu Date: /02/j <br /> Title: Ir dyt 1s �e1� <br /> DO NOT WRITE BELOW THIS LINE= <br /> REHS Application Approval: _ _ �}JL.-.—. _ Date: 2adi- <br /> Expiration gate: 1 ./,� bl, Date Paid: I-24 f!Cash or Check#: Received By: l✓ <br /> END 4&0111129/11 APPLICATION FOR A IMFEO QUANTrrY rlAuuNG F-XErAPTION <br />