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PquIN <br />'o c° SAN JOAQUIN COUNTY <br />R { EN4W- NMENTAL HEALTH DEPART Pq E <br />, N% <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 952 -27 �VEp <br />09 } . w <br />a Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: ww.s r E <br />`RN 14 2004 <br />APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPT' !Z*AQUINooI <br />NI <br />HFACTy pE A�MTqL <br />To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Act", the toiking <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 <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />Medical Waste Hauler Information <br />❑ New `b Renewal <br />Medical Office/Business Name: <br />Medical Office/Business Address: <br />Contact Person: <br />Phone Number: <br />Storage Facility Name: <br />Storage Facility Address: <br />Permitted Treatment Facility Name: <br />Permitted Treatment Facility Address: <br />"I7t L -r:.) Y,,w,ri r <br />Lf� Ki <br />,::far.r:.. <br />City State <br />Zip Code <br />t1.cr;10113-c�c,g;, <br />City State <br />qtr I( YC I E iOC' <br />Zip Code <br />TV f-- Ic} <br />Ci "lJ 2 <br />City State <br />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: n F C ca tl;ac hr-�� 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, all copies of medical waste records shall be kept on file at generator's or health care professional's facility. <br />Applicant Signature: <br />Title: <br />Date: 12- S - 0,y <br />DO N T WR TE BELOW THIS LINE <br />R.E.H.S. Application Approval: Date: �/i/ <br />Expiration Date: /3L/Q Date Paid- /7 / l / d Cash or eck �' a� eceived By: <br />EHD 45-02-001 <br />10/7/2003 <br />