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aqui <br />SAN JOAQUIN COUNTY <br />ENR4MHEALTH DEPA <br />TvENTFILE <br />4 ' <br />600 East Main >Street, Stockton, CA: 95202-3029 <br />Telephone: (204)'468-3420 Fax: (209) 468-3433 l3je11: www.sjgov,org/elid <br />�«�oRcti� <br />APPLICATION FOR A LIMITED QUANTITY UAUL;IiNG 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 onetime, 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 Targe quantity generator. <br />or a small, quantity generator required to register pursuant to Chapter 4. <br />2- Aformation 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 miaiil with $77.00 fee to: <br />Sari Joaquin CountyEnvironmental Health DepaAment <br />Medical Waste Management Program <br />500 East Macri Street, Stockton, CA. 95202-3029 <br />Medical Waste Hagler Information <br />0. New -ionewal <br />Medical Ol'fceLBusiness Name: Al .:;Eez 6)ct I (: tiyF_Zdl- &C <br />Medical Office/Business Address:S D t> t e� S _� /f c'Sfi; %L X c <br />�lG'ityState• Zip Code <br />Contact Person: <br />Phone Number.- <br />Storage <br />u ber Storage Facility Name: � ,F <br />Storage Facility Address: <br />Permitted Treatment Facility Name: <br />Permitted Treatment Facility. Address. <br />city State, yip coati <br />List all employee names and titles authorizedto transport the medical waste (If more than 3, attach info): <br />1 Name: 'ec* IE Title: i �eSE.CL�E/ir�G 'Uie�E it-e4krl01 s w� <br />2. Name FIC F d Title: !:�S e't> <br />3. Name: i FZ /I X 0cs 1,V- 1 Ar e, Titley <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, alt copies of ntedigaf waste records shall be kept on file at generator's or health, care professional's fagility.. <br />Applicant Signature: <br />Title:c <br />Date: <br />DO NOT WRITE BELOW THIS LINE <br />R.E.H. ;. Application Approval. ___Date. _&k/_.— <br />Rkpimt anDate- ( 3 / I L Date Paid: 4-2_/31 / / l Cash or Check #.5�` 1` Received By <br />Eztn 4s-ai �i�ri <br />