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��,tA,u F rta C <br /> SAN JOAQUIN COUNTY <br /> ( rn ` W4 E ONMENTAL HEALTH DEPARTWT <br /> ® :, 9 <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/eh � <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 $77.00 fee to: PAYMENT <br /> San Joaquin County Environmental Health Department RECEIVED <br /> Medical Waste Management Program ��Y. 2008 <br /> 600 East Main Street, Stockton,CA 95202-3029 SAN JOAQUIN COUNTY <br /> Medical Waste Hauler Information ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ❑ New j2f Renewal <br /> Medical Office/Business Name: -S-1 - is <br /> Medical Office/Business Address: ' as eti <br /> A _ ckftf— C <br /> City State Zip Code <br /> Contact Person: - Keod if, <br /> Phone Number: 4 - <br /> Storage Facility Name: ,, �t`S o C t <br /> Storage Facility Address: 1 t,�, C� y- -� 't- - <br /> n c i:� 7 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: 1- - `° C. A <br /> Permitted Treatment Facility Address: 1 t - `` , e." <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: Title: <br /> 2• Name: Title: <br /> 3. Name: Title: <br /> A copy of this exemption and a tracking document skkll be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical waste records shall 4#kept on file at generator's or health care professional's facility. <br /> Applicant Signature: --��`� ', Date: U-13 <br /> Title: D;t-e C;;tr 1 tn' &IL12�>-1- <br /> I if <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: _ Date: -!�VA/PT <br /> Expiration Date: / 1 / b Date Paid: / / Check Received By: <br /> EHD 45-01 <br />