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03/23/2005 11 :23 FAX 2093 93 ST. JOSEPHS MEDICAL Ia003/006 <br /> ° t`N' to 616 SAN JOAQUIN COUNTY • <br /> „• <br /> 't <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> . 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax,(209)468-3433 Web:www.sigov.org/chd <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$70.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical'Waste Management Program 0 <br /> 304 East Weber Avenue,3`d Floor,Stockton,CA 95202 0Z <br /> Medical Waste Hauler Information <br /> ❑New [I Renewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: Jed Mr.1,1f" <br /> City State Zip Code <br /> Contact Person: <br /> Phone Number: Ai-%7- G`17 <br /> Storage)Facility Name: f o - <br /> Storage Facility Address: ! av A,- f",21 f . <br /> City State Zip Code <br /> Permitted Treatment Facility Name: ST o du <br /> Permitted Treatment Facility Address; i qiwdif . <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: if '1,��� 1 Title: <br /> 2. Name: Title: <br /> 3.Name: Title: <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,211 copies of medical waste reeo $ham kept on file at generator's or health care professional's facility. <br /> Applicant Signature: 2_1L_ Date: <br /> Title: ,:ue e&t/, �' r <br /> DO N T WRI BELOW THIS LINE <br /> R.E.H.S.Application Approval; Date: 1231j26__ <br /> Expiration Date: JZ/ 31 / S ap to Paid: ( /20 / 05- Cash or Check#: 200 1S-3 Received By: <br /> EHD 45-02-001 <br /> 101712003. <br />