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{U 1!y C <br />o�Z SAN JOAQUIN COUNTY <br />{ ENOONMENTAL HEALTH DEPART m <br />600 East Main Street, Stockton, CA 95202-3029 t. Tele hone: 209 468-3420 Fax: 209 468-3433 Web: www.s' ov.or ehd GOP <br />cgtiFo>z��P P � ) � ) JS � <br />APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <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 $72.00 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 f 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 />C1 l State Zip Code <br />GLAI to -2_u7'-Q5 i-[- Lo 5-&a I <br />Permitted Treatment Facility Name: <br />Permitted Treatment Facility Address: <br />City State Zip Code <br />. J� <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: MaCP% Title: �, <br />2. Name: A I-) Title: <br />3. Name: 10 cA n)Cl u) S Title: rf )MA (An r. <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 />Applicant Signature: r A,4 Date: <br />Title: —V � <br />DO NOT WRITE BELOW THIS LINE <br />R.E.H.S. Application Approval -Date: T -10i <br />Expiration Date: 015'*/Date Pa1d: / ,3 /JIK Cash or Check #: qRd ,?,jcj Received By: <br />EHD 45-01 <br />10/02/07 <br />