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u ' <br /> y oa �j SAN JOAQUIN COUNTY <br /> 4 <br /> r <br /> ENVIRONMENTAL HEALTH DEPARTMENT e tE t <br /> 304 East Weber Avenue,P Floor, Stockton, CA 95202-2708 ��06 <br /> �P• Telephone:(209)468-3420 Fax:(209)468-3433 Web.www.sjgov.org/ehd L' <br /> L PDR <br /> N JOAQJIN C-00r Y <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIOS EIyVIpONT.�AENTAL <br /> HEALTH DEPARTMENT <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 /> " 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 required <br /> to register pursuant to Chapter 4. <br /> Please complete the information below and mail with $72.00 tee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 304 East Weber Avenue,P Floor, Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> ❑New enewal <br /> Medical Office/Business Name: ST. —y5tT S <br /> Medical Office/Business Address: 19 0 D rU p?-,rK c4v—I,0 P-t1i t lat I _.T- <br /> sTn C4!-4-V r+ C/A _.. CTsd--04 <br /> City State Zip Code <br /> Contact Person: SatiT, Kr�,7NDLz <br /> Phone Number: <br /> Storage Facility Name: ST . 'j t3S pHs }.,IED icA-t— O iJTM <br /> Storage Facility Address: /gD "-F <br /> CA q5-31-D4 <br /> City State Zip Code <br /> .Permitted Treatment Facility Name: 54- SSP Ffi` OE7D Com- C-eN I <br /> Permitted Treatment Facility Address: N 04"4 1 A- :2 T <br /> S�t,l p _._ 951 <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: SL-t; ��FPTTitle: <br /> 2.Name: _ Title: <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 <br /> addition,all copies of medical waste rec ds shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: C, _Date: 14 /0 <br /> Title: TAt2.IEUPEW— <br /> D <br /> DON T WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: IZ/�/0(p <br /> Expiration Date: �/ 31 /Date aid: !z / 1 S/U Ca Cash o heck :4taV0-6y Received By: &f6 <br /> EHD 45-01 <br /> 07/31/06 <br />