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o .° cQG SAN JOAQUIN COUNTY <br /> N� <br /> E1 ONMENTAL HEALTI-i DEPAR l NT C(DFY�. <br /> 304 East Weller Avenue, 3rd Floor, Stockton,CA 95202-2708(209)468-3420•Fax:(209)468-3433 • )1�r�i:%v -joaquiit.ca.tlslehct <br /> APPLICATION FOR A LIMITED QUANTITY I1A.ULING EXEMPTION <br /> To qualify for a"Limited Quantity Hauling Excluption"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 weep,transport less <br /> than 2.0 pounds oi'rnedical waste at any one time, maintains a tracking docuntent pursuant to Chapter 6 and the <br /> generator or parent organization has on file one of the following: <br /> 1. Mrclicirl t-Ycr,tite A�n!icr�elnent Plcrir ifthe generator nr p:trcltt r3rt;anizzttion is a large quantity geucrator <br /> ora small yuantily generator required tc,t'cgisl.er pursuant tc't.'haptcr 4. <br /> 2. Information Document if the generator or parent organization is a small gUantity geiierator,`tot required <br /> to register pursuant to Chapter 4. <br /> Please compleife the information below and 1nta'al with S70.001fed. to: <br /> San Joaquin Cbunty Envirolinlcntal Ilealth Den.qrtrnent <br /> Medical Waste Nl,�Lnagentent Program <br /> 304 Fast Weber avenue, 3rd Floor, Stockton, CA 95242 <br /> Medical Waste Hauler IllfoI' III ati011 <br /> ❑ New �ie ewal <br /> Medical Office/Business Name: (6wtl _ _---- <br /> Medical Office/Business Address: <br /> - - <br /> Contact Person: City --/�-,�--�--------------�----_-St.�te-___.---------Zit.Code_ S�t� ✓n����-- _..____ _ _ __ . <br /> Phone.Number: <br /> Storage Facility Name: --_-,��=Ti s71A1 r e4141 <br /> Storage Facility Address: <br /> City State -_-- Zip Code <br /> Permitted Treatment Facility Name: — �� `r Aed ('we- _ <br /> Pennitted Treatment Facility Address: — Uu_/V. C,/( <br /> ' - — <br /> Cit - <br /> y State Zip Code <br /> List all employee names and titles authorized to transport the r,idical Nvaste (if mc;re irlan 3,attach info): <br /> 1. Name: fi e &,Aq a d,P,4w - _ 'ri tic,: <br /> 2. Naine: - __---- - ----- Title: - ---_—--- _ --_- -_ <br /> 3. Nanic: _—� --- ------ — Title: ---- <br /> A copy of this exemption and a tracking 4ocurnout shalt be in employucls posscssiNl at:tlf time::NYWIC lr: r;vorfing medical waste. In <br /> 'Addition,all copies of medical Fvaste recd s 511.11f be kept ort fife at gerleratar's or l:ealtii car;prorewon is fai•Elity. <br /> Applicant Signature: - - _1/%I �jq`L -�- ------_------- Date: _-��! v` <br /> Title: - <br /> � _ w - /It/!up 7,/ c <br /> DO NOT WRITE BELOW THIS LINE <br /> R.C.H.S. Application Approval: <br /> Expiration Date: _/L/ �� 1 Date Paid: —i a T{ 01 Cu 110 ;: /�3,3 e5-Veceived By: — <br /> £HU 45-02-001 <br /> i on/2003 <br />