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� SAN JOAQUIN COUN'T'Y � <br /> G <br /> EOONMENTAL HEALTH DEPART _ 'C <br /> ( 304 East Weber Avenue, 3Floor,'d FlStockton CA 95202-270 <br /> 8 <br /> 0 <br /> (209)468-3420•Fax:(209}468-3433 • Well:w-%vw.co,s;in-joaqtiiii.ca.us/clict <br /> \tIVOK��. <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 regist.cr pursuant to t_'hapter 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 compleie the information below and mail with $70.00 fee to: <br /> San Joaquin C,bunty Environmental Ilealth DengrtmPnt <br /> Medical Waste N14nageuient Program _ <br /> 304 East Weber Avenue, Yd Floor, Stockton, CA 95202. <br /> Medical Waste Hauler Infornlatioll <br /> ❑ New JaR6newal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: <br /> City -------..--- ---------State - ----r,i1)Code <br /> Contact Person: _ f f�y_��i41 ��t•• -- ------ - <br /> Phone.Ntimber: - <br /> Storage Vacility Name: <br /> Storage Facility Address: leoo //. 7 <br /> 24) <br /> City Stale Zip Code— <br /> Permitted Treatment Facility Name: <br /> Pennitted Treatment Facility Address: <br /> ate--` -- --__--------�J-.ZGL --.. <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the radical waste(If morn- than 3,attach info): <br /> 1. Name: ---- fie v4dg6,C4 ill 44-f 'Title,: <br /> 2. Name: Tittc: — ------------------ <br /> 3. Name: ----- — ------- Title. --------------- ----- <br /> A copy of this exemption and a tracking document shall be in employee's possemieu at all times w!,ilc trinsportini;medical waste. <br /> s Int <br /> addition,all copies of medical waste reco shall be kept on file at generatar's or heaitit care professiona rs family. <br /> Applicant Signature: — _ _//1� --- --------------Date: v�— <br /> Title: <br /> DO NOT ii' ILI E BELOW THIS LINE <br /> R.E.H S. Application Approval: Date: <br /> Expiration Date:-j 31 / Date Paid: _a2 /Y3,F I?5 F:rceivcd Fay: — <br /> E11D 45-02-001 <br /> i on/2003 <br />