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JAN-03-2007(WED) 16: 11 LMH"acilities Management (FAX) 339 7672 P. 002/004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DE'PAR'TMENT <br /> 304 East Weber Avenue,3rd FIoor,Stockton,CA 95202-2708 <br /> Telephone.(209)468-342()Fax;(209)468-3433 Web:www,sjgov.org/ehd <br /> APPLICATION FOR.A LrAUTED QUANTITY I-JAU ING EXEMPTION <br /> To qualify fora"Limited Quantity IIauling Exemption,,ptusuant to the"Medical Waste Management Act",the following <br /> conditions must he met: g <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 /> 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 genctator or parent organization is a small quantity generator not required <br /> to register pursuant to Chapter 4. <br /> Please Complete the information below and mall with$72.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 304 East Weber Avenue,3rd Floor,,Stockton,CA 95202 <br /> Medical 'Waste Hauler Information <br /> D New p Renewal <br /> a r 1�'j NIO�f trc. f-�os P l 77� l,�'1 <br /> Medical Office/Business Na <br /> Medical L[0M C-14E4LT1q <br /> Medical Office/Business Address: l L)IT/�S <br /> -a <br /> Contact Person: City State <br /> Zip Code <br /> Phone Number: <br /> Storage Facility Name: <br /> Storage Facility Address: Is -i-�-- <br /> City state <br /> .Permitted Treatment Facility Name: �j Zip Code <br /> Permitted Treatment Facility Address: <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: <br /> 2.Nae: Title <br /> Name: <br /> 3.Name: Title: <br /> 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 rile at generator's or health care professional's facility. <br /> AppliM=: <br /> Title: Date:.' <br /> D0 NOT WRITE Bk;LOW TII.IS LINF, <br /> R.EJI.S,Application Approval: <br /> Date: <br /> Expiration.Date: / /0F Date Pa d. l-7 ` <br /> / Cash or Check ft; Received By; <br /> 8Hb 45.01 f- <br /> 07/31106 <br />