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>{ L, <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 20® <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd �J <br />APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION SANr�tvI�r <br />HEp.Lfr1 nE PPkF VIEN <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 $72.00 fee to: <br />San Joaquin County Environmental Health Department <br />Medical Waste Management Program <br />304 East Weber Avenue, 3`d Floor, Stockton, CA 95202 <br />Medical Waste Hauler Information <br />❑ New 'Renewal <br />Medical Office/Business Name: _'_lA 13LOM eta►,! <br />Medical Office/Business Address: b5 1,1. COtit re-cy- -=,-r. <br />=nOct arm t CA <br />City State Zip Code <br />Contact Person: Q-A�Qn 1 jbQ—E ,T2 <br />Phone Number: (00ca) g4338W <br />Storage Facility Name: <br />�XEL-g Jj <br />c <br />Storage Facility Address: <br />t cc i(r`x i, <br />cyA <br />Ct tJ2 <br />City <br />State <br />Zip Code <br />.Permitted Treatment Facility Name: <br />1-yuc. eco <br />Permitted Treatment Facility Address: <br />4 i sF5 <br />Lo, sioLFs ode. <br />F EnNs) <br />CA <br />q W ata, <br />City <br />State <br />Zip Code <br />List all employee names and titles authorized to transport the medical waste (If more than 3, <br />attach info): <br />1. Name: SIDU C-nclo <br />tF D <br />Title: <br />2. Name: <br />Title: <br />3. Name: <br />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: ; csr Date: 12--Z2-0j, <br />Title: CcMPLACNIC'C OFA1[Ej� <br />DO NOT WRITE BELOW THIS LINE <br />R.E.H.S. Application Approval•�,7 I D _ Date: <br />Expiration Date: /Z l 31 /Date Paid: \2-/ / -C-as" Check #: S 3 Received By: lJ <br />EHD 45-01 <br />07/31/06 <br />