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°tau °o SAN JOAQUIN COUNTY <br />ENSONMENTAL HEALTH DEPARTN&T FILE COPY <br />600 East Main Street, Stockton, CA 95202-3029 <br />• CC ;p Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <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: PXM E N <br />San Joaquin County Environmental Health Department <br />Medical Waste Management Program 9 SOU <br />600 East Main Street, Stockton, CA 95202-3029 SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />Medical Waste Hauler Information HEALTH DEPARTMENT <br />Q New Q 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 />ko, ) I HE'NOR /14 C. F+oS p 177P -L , 1,Aq 40AI E f �C4L� <br />UIEV rare /.in r :one <br />%,uy I -1p wuc <br />7765 <br />w -y Owac c.iy \,L)uv <br />List all employee names and titles authorized to transport the medical waste (If more than 3, attach info): <br />1. Name: Title: <br />2. Name: Title: <br />3. Name: 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 rec rys shall be kept on file at generator's or health care professional's facility. <br />Applicant Signature: Date: -2 - - d <br />Title: . S,4P�=-y <br />F <br />ZfPai <br />T WRITE BELOW THIS LINE <br />R.E.H.S. Application ApprDate: <br />Expiration Date: 1 9 /0 7 CashCheck . 6�;,5 Received By: (46 <br />EHD 45-01 \, 1Z /3I /0 <br />10/02/07 r4vo00 <br />