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tau 'c SAN JOAQUIN COUNTY <br /> 2 .o <br /> ENOONMENTAL HEALTH DEPARTAIkT J , <br /> 600 East Main Street, Stockton, CA 95202-3029 f L � <br /> 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 get )t required <br /> to register pursuant to Chapter 4. <br /> Please complete the information below and mail with$72.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 PAYMENT <br /> RFCFIO/Fn <br /> Medical Waste Hauler Information D 14 2007 <br /> Q New Renewal <br /> SAN JOAQUIN COUNTY <br /> ( - ENVIRONMENTAL <br /> Medical Office/Business Name: SbSfl l •S MEVOrt, C'ENTE9 HEALTH DEPARTMENT <br /> Medical Office/Business Address: k" 11J®-24h CAtJ MD ,7N r Pt 9TX CT <br /> City State Zip Code <br /> Contact Person: i1 NKuwtote <br /> Phone Number: �_t� <br /> Storage Facility Name: ST- -j--DSffii''S KfEDIC41-U 6,-IV7'&7-P, <br /> Storage Facility Address: two W KTH C0 AfflK1VIH- �5-WCF-T <br /> SDc.KTVr-1 CA C15�Oct <br /> City State Zip Code <br /> Permitted Treatment Facility Name: ST„ P S t ett L s M•E-D i GA-(_ C."T►TTFrL <br /> Permitted Treatment Facility Address: 1 eft N 0 9:2f C.Atli fe YL-N i a STET <br /> ,sem c4 CA gsa-d q <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: Std A'TTfl &rJT Title: <br /> 2. Name: Title: <br /> 3. Name: Title: <br /> i <br /> A copy of this exemption and a tracking document shall be in ployee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical waste recor s shall be kept ile at generator's or health care professional's facility. <br /> Applicant Signature: _ Date: <br /> Title: 06*472614s s Y-- C-6-1 <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: <br /> Expiration Date: / Date Paid: lcx, '1/0 Cash or ec Received By: <br /> HID 45-01 <br /> 10/02/07 <br />