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SAN JOAQUIN COUNTY <br /> PAYMENT <br /> 1EA10NMENTAL HEALTH DEPARTAT RECEIVED <br /> 304 East Weber Avenue,Yd Floor, Stockton,CA 95202-2708 <br /> (209)468-3420-Fax. (209)468-3433 - Web:www-co.san-joaquin.ca.us/ehd DEC 2 9 2003 <br /> 1*6t"Nvoo <br /> COUN <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTI(SAN JOAQUIN)NVIRONMENTALTY <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$70.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 304 East Weber Avenue, 3d Floor, Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> 0 New Renewal <br /> Medical Office/Business Name: C'r i(4N hjejP,',1,41 <br /> Medical Office/Business Address: " <br /> T 4 1AIJ <br /> I city CIL—9S.' State Code <br /> Contact Person: —DAV;Le CA 2A ve io 7)2 r r V z.' <br /> ptc'4 <br /> Phone Number: ch A 194—le- <br /> Storage Facility Name: 5.4 in el as A 66ve- <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: j3.,-tS- Q001 '14/ <br /> C1+ CM-TZ <br /> City State Zip Code <br /> List all employee names and titles aythoriZpdAo transport the medical waste(If more than 3,attach info): <br /> 1.Name: Z"Si Title: <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 reobrd11 be kept on file at generator's or health care professional's facility. <br /> Applicant Signature:'Ea'j r-ymz, Date: WN103 <br /> Title: 1'ev"y( A-S/f Iftqr t <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: <br /> Expiration Date: Date Paid: Cash or 0ep:J)�� Received By:ic- <br /> EHD 45-02-001 <br /> 10/7/2003 <br />