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SAN JOAQUIN COUNTY <br />0 DRONMENTAL HEALTH DEPARTWT <br />P600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />on k�, -� �' SANJOAQUi EVTq��rY <br />` 4 1WPLICATION FOR A LIMITED QUANTITY HAULING EXEMP IFI+ DFpAR-rME <br />C , N7 <br />To qualify 0Vitt. <br />d Quantity Hauling Exemption" pursuant to the "Medical Waste Management Act", the following <br />co �" ��, \ <br />l <br />71' f�e 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 $77.00 fee to: <br />San Joaquin County Environmental Health Department <br />Medical Waste Management Program <br />600 East Main Street, Stockton, CA 95202-3029 <br />Medical Waste Hauler Information <br />❑ New Renewal <br />Medical Office/Business Name: 1-- U-✓ <br />Medical Office/Business Address: % 7 0,4S4-- <br />Contact Person: <br />Phone Number: <br />Storage Facility Name: <br />Storage Facility Address: <br />Permitted Treatment Facility Name: <br />Permitted Treatment Facility Address: <br />City State Zip Code <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: mCi 4e [% T\ Title: Ikliwj:_( <br />2. Name: .CC {' /C J- Title: ��-A--e- C&Y- ; �,1`r7f 7-k-. <br />3. Name: Jvl 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 waster records shall be kept on file at generator's or health care professional's facility. <br />Applicant Signature: -- <br />t1/3 <br />Title: US L�.a car U% <br />Date: /2-- ;7`�oc,� / <br />DO NOT WRITE BELOW THIS LINE <br />R.E.H.S. Application Approval: ��� �L ., l l_�.i., Date: Com/ /�/y <br />Expiration Date: /I -/-5L //) Date Paid: Cash �eok- 306LU S � Received By: <br />EHD 45-01 <br />