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'O N9L u 114 <br /> SAN JOAQUIN COUNTY <br /> 0: ENS#NMENTAL HEALTH DEPARTM10 <br /> Cod <br /> 304 East Weber Avenue, 3Td Floor, Stockton,CA 95202-270 <br /> • �� � P Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.+)hd] <br /> APPLICATION FOR A LIMITED QUANTITY HAULING E"�90N,4 <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the "Medical Waste Mpagement rAct'„',the following <br /> t fit+ <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, 3`d Floor, Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> ❑ New Renewal <br /> Medical OfficeBusiness Name: t cti11 IMIEC,11 At-ap: .� <br /> Medical Office/Business Address:. L, fi <br /> City State Zi Code <br /> Contact Person: rav rr - c <br /> Phone Number: c 01 \C( 19 <br /> Storage Facility Name: <br /> Storage Facility Address: ,S A <br /> City State Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: I �(� of f)t « P <br /> �•y1 ���v�C 1rc L ci `77 <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: Title: <br /> 2. Name: Title: <br /> 3. Name: Title: <br /> A copy of this exemption and a trackin document shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medic waste re rds sh 1 e kept on file at generator's or health care professional's facili P. <br /> ,1 <br /> Applicant Signature: Date: <br /> Title: ? N, Qc, t <br /> DON T R BELOW THIS LINE <br /> R.E.H.S. Application Approv Date: /Z/3D/� <br /> Expiration Date: Date Paid: / / Cash or Check#: f(o x! 9��-Received By: [� <br /> EHD 45-02-001 <br /> 10/7/2003 <br />