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.•5pg•,� .: r...CO <br /> o SAN JOAQUIN COUNTY <br /> r� { EN :ONMENTAL HEALTH DEPARTN. 4T <br /> 600 East Main Street, Stockton, CA 95202-3029 FIL <br /> �4 Telephone.(209)468-3420 Fax.(209)468-3433 Web. .lg � dov.or eh www.s' � <br /> CrxatizT� <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 /> i <br /> The generator or health care professional generates less than 20; <br /> than 20 pounds of medical waste at any one time,maintains a tri tt.JosepNs Medical Centerle; <br /> �P <br /> generator or parent organization has on file one of the following Amemberofcxw <br /> 1. Medical Waste Management Plan if the generator or, <br /> or a small quantity generator t <br /> required to register purl <br /> q g h John Kendle 1600 North California Street <br /> 2. Information Document if the generator or parent or director of Operations Stockton,CA 95204 <br /> g. Support Services 209.467.6471 direct <br /> to register pursuant to Chapter 4. john.kendle®chw.edu 209.943.6293 fax <br /> StJo5ephsCares.cr9 r <br /> Please complete the information below and mail with$72.00 fee to: . <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 PAYMENT <br /> Medical Waste Hauler Information RFCEIVFD <br /> DEC Z 4 2007 <br /> C] New Renewal SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> Medical Office/Business Name: gF` 3b -hf $ N E)I CAL CUN TEHEALTH DEPARTMENT <br /> Medical Office/Business Address: t J 01 CAij MieN11+ <br /> ptguT <br /> City State Zip Code <br /> Contact Person: <br /> Phone Number: �toP4 1 <br /> Storage Facility Name: S77j�,5"fj S 4Uprr->9 U Cf-79`7-&-je, <br /> Storage Facility Address: IWO NOICTW C t4P0,C1V11+ 51p-UE�T <br /> ` MOgDN C4 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: S4-- PSUPfi l..5 M-EDl CA-L Cp-jq =L7. <br /> Permitted Treatment Facility Address: 1W_ Nz) C.A"P6-#?of r a STf-eIFT <br /> c r C 'TS <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. <br /> nfo):1. Name: SETT A-T r eft-t�,C—t%rl Title: <br /> 2. Name: Title: <br /> 3. Name: Title: <br /> i <br /> A copy of this exemption and a tracking document shall be in pioyee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical waste recur s shall be.kept de at generator's or health care professionai's facility. <br /> J <br /> Applicant Signature: Date: t7' <br /> Title: I grilaK !aL-ON-K, <br /> d�^' S uI®Pdie t G� <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: <br /> Expiration Date: / Date Paid: /d ��!Cash or ec Received By: <br /> EHD 45-01 <br /> 10/02107 <br />