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SAN JOAQUIN COUNTY CF 7 <br />l�/E-® <br />ENVIRONMENTAL HEALTH DEPARTMENT JAN <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 5 20�� <br /><< Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd SANJOAgUt <br />IAEA T� paNM�NTIIN�' <br />APPLICATION FOR A LIMITED QUANTITY HAULING EMPTION EPARrjy Nr <br />To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Wa a erti 1Ac <br />conditions must be met: <br />llowing <br />U <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 TT aste 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 $72.00 fee to: <br />San Joaquin County Environmental Health Department <br />Medical Waste Management Program <br />304 East Weber Avenue, 3" Floor, Stockton, CA 95202 <br />Medical Waste Hauler Information <br />F1 New Z Renewal <br />Medical Office/Business Name: <br />Medical Office/Business Address: <br />Contact Person: <br />Phone Number. - <br />Storage Facility Name: <br />Storage Faci I i ty Address: <br />.Permitted Treatment Facility Name: <br />Permitted Treatment Facility Address: <br />1x �Ity _ 1 State Zip Code <br />Llty State Zip Code <br />�..� OLa« Glp uoae <br />List all employee names and titles authorized to transport the medical waste (If more than 3, attach info): <br />1. Narne:j / ¢ Title: -V (A <br />C. F <br />2. Name: %%/ Title: <br />3. Narnc: 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 records shall be kept on file at generator's or health care professional's facility. <br />7 l} <br />Applicant Signature:Date: <br />Title: <br />DO N T WRITA BELOW THIS LINE <br />R.E.H.S. Application Approval: Date: <br />Expiration Date: / 0 9 -E�r Check #. 2 3 Received By: G_ <br />EHD 45-01 <br />07/31/06 <br />