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<br />° EP,4' <br />`.�_ '.`r` <br />`'`_rr VDEPARTMENT <br />600 East Msin S et, Stockton CA9§202-3029 <br />, <br />TelePhone. (209) 468-3420 Fax. (209) 468-3433 Web: www.sjgov.org/chd <br />APPLICATION FOR A LIMITED QUANTITY HAULING EXE �'r' .:Jt�tp1 r <br />A%V�;�1v.�;Fr F,- i,Vjy <br />To qualify fora "Limited Quantity Hauling Exemption" <br />HE "11- <br />`'�:°'�F�L <br />S P pursuant to the "Medical waste Management Act", the" JofWMg <br />conditions must be met: <br />The generator or healthcare professional generates Iess 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 />I . 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 luformation below* and mail with s77.00 fee to: <br />San Joaquin CoLvn?y Environmental Health Department <br />Medical Waste Management Program <br />600 Fast Main Street,, Stockton, CA 95202-3029 <br />Medical Waste ler Information <br />D New Renewal <br />Medical Office/Business Name: <br />Medical Office/Business Address: <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 />c.say State <br />Zin (''rarlP <br />`1`' state Zip Code <br />List all employee names and titles authorized to transport ical waste (If more than 3, attach info): <br />1. Name: li° A.40ij Title: (A%ettwesS <br />2. Name: .e "# d Title: I <br />3. Name: I <br />Title: Cob <br />A copy of this exemption and a tracking document shall be in employee's possmieft at all tiaras while transporting medical wash to <br />addition, all coples of medical waste arils shall be <br />f'e kept an l5te at is or health care •prolfe�anal's facility. <br />� ��si�. <br />at <br />EM-MMIr <br />�s is + 7M <br />DO NOT WRITEBELOW TH <br />IS LINE <br />R.E.H.S. Application . iApproval. <br />D• Paid: <br />i� 3a y, ,/ k " s. <br />