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MAY-03-2004 MON 03:00 PM FAX NO, P. 02/02 <br /> o SAN JOA QUIN,COUNTY <br /> ENVIRONMENTAL lffiAum DEPAXIMENT04 East Weber Avenue,venue,P Floor,Stockton,CA 95202-2708 <br /> (209)468.3420-Fax:(209)468-3433 - Web, wwwxo.san-joaqtdn.ca.u*hd <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 core 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, Itiformallots Document if the generator or parent organimlion is it small quantity generator not required <br /> to register pursuant to Chapter 4. <br /> Pleaso complete the Information below avid mail with$70.00 fee to: <br /> .,an Joaquin County linvil al Hcallli Depattilient <br /> Medical Waste Management Program <br /> 304 East Weber Avenue,3"Hoor,Stockton,CA 95202 <br /> Nedlegl Waste Hauler ji1for ))LatL0_1) <br /> Now (3 Renowal <br /> Medical Office/Business Name., 1Dac4,ora II -f Arte-ca- <br /> Me,dical Office/Business Address: 1205 E. North Street <br /> City State Vnp Code <br /> Contact Person: -Carmen Silva,., c6b/009 <br /> Phono Number: <br /> Storage Facility Name: Dggtgrs Hog4r)i f-.41 of man.taca- <br /> Storage Facility Address: 1205 E. North SttaAt <br /> mantggp__ CA, <br /> City State Zip Code <br /> Permitted Treatment Vaellity Natne: Stover icycle <br /> Permitted Treatment Facility Address: 413 5 W. Swift Ave. <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste(If tnore than 3,attach info): <br /> I.Narne: Jeremy McI1xa1,n_ Title:`, Director EnvironmentAl Svcs <br /> 2.Name: Geri Quinn Title: AM Lead/Ilousekeej2er <br /> 3.Name: gfierry Tau Title:_714 Lead/Housekooper <br /> tsee ar-taa for adafitiznall naffgsl <br /> A copy of this.exemption and a tracking document shall be In employee's possession at all jillics while tralisporting medical waste. In <br /> addition,all copies of medical was��Ijrqcords shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: Date: <br /> Title: Chi f Expq!atiyg._ <br /> DON,OT WR E BELOW THIS LINE <br /> R11,11.S.Application App rov : A(AA4M_ u. Date: -L/.7,/q( <br /> Date Paid; Cash or Clieck#: 06R02g <br /> _7 11061".M_ <br /> Rxpiration Date: YReceived By. <br /> FEID4"2 <br /> W/200 y, <br />