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oAQ1J11V• PAYMENT <br /> ?.. .E:.� SAN JOAQUIN COUNTY RECEIVED <br /> N - ENVIRONMENTAL HEALTH DEPARTMENT DEC Z 3 2013 <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> • cq :-��P (209 468-3420 Fax: 209 464-0138 Web: www.s ov.or /ehd RAN ENVIRONMENTAL COUNTY <br /> ��POR ) ( ) Jg g ENVIRONMENTAL <br /> HEALTH DEPARTMENT <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, transports 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 or a <br /> 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 to <br /> 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 APPROV of 7 it <br /> Medical Waste Management Program0 2014 <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 'I a A� <br /> Medical Waste Hauler Informatlon "" <br /> New E Renewal <br /> edical Office/Business Name: Channe-1 yip-dical renters <br /> Medical Office/Business Address 701 E. Channel St- . <br /> Stockton, CA 95202 <br /> City State Zip Code <br /> Contact Person: Qi Coordinator <br /> Phone Number: (209) 373-2800 <br /> Storage Facility Name: _ 'fit. At Atpue <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: en0• <br /> Permitted Treatment Facility Address: 415 q W- Sw;-'+ Z <br /> etu sr.» CA <br /> City State Zip Code <br /> List all employee names and titlesauthorized to transport the medical waste (If more than Z, attach info): <br /> 1. Name: AI\W( Imp Uh(4 •ehtt_ Title: IA-G 1 Mk (t�I M V V <br /> 2. Name: V1y- lfk�(\ \V YA . Title: -t h £ U.0 <br /> 3. Name: MWYM ?j(AC-, �1r1 (1 Title: f;CV,( S I� <br /> r L*ate <br /> A copy oft Is exemption and a tra king document shall be in employee's possession at all times while transporting medical waste. In addition,all copies of <br /> medical waste records shall be kept on fat ge ator's or alth care professional's facility. <br /> 3 <br /> Applicant Signature: Date: <br /> Title: <br /> PAYMENT <br /> 0 DO NOT WRITE BELOW THIS LINE RECEIVED <br /> REHS Application Approval: Date: 01114 /14DEC 2 3 2013 <br /> SAN JOAQUIN COUNTY <br /> IRONMENTAL <br /> Expiration Date: / /4 Date PaidA2- /Z�/� (�� <br /> Cash or Q I�J ENV134 RBCeived By: LTH DEPARTMENT <br /> EHD 45-01 5/2/12 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />