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qu <br />SAN JOAQUIN COUNTY <br />z EN#NMENTAL HEALTH DEPARTM&FIL <br />E Copy600 East Main Street, Stockton, CA 95202-3029 <br />P Telephone: (209) 468-3420 Foix. (209) 468-3433 Weh: www.sjgov.org/ehd <br />q��ROR <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 $72.00 fee to: <br />San Joaquin County Environmental Health Department <br />Medical Waste Management Program <br />600 East Main Street, Stockton, CA 95202-3029 <br />Medical Waste Hauler Information <br />Q New MRenewal <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 />99M <br />l.5 wi. coHHEfcce ST . <br />STocr ptwj CAq 45�o2. <br />City State Zip Code <br />ELAYD(:4 -PbQF�C, <br />(,-)OR) Qua --Be so <br />�-k l a IRA C .) 1aaV► V- <br />U 5 V.1. erprtr-rr=ly r� r` lar. <br />sToct7 o. i CA R5�o2� <br />City State Zip Code <br />Permitted Treatment Facility Name: CTEe,ccct_ - 1uc . <br />Permitted Treatment Facility Address: Lh5 Q. 5tok i= r Ave. <br />Fe -ES 1.►Q C-4 q:5-7 2,2- <br />city <br />2City State Zip Code <br />List all employee names and titles authorized to transport the medical waste (If more than 3, attach info): <br />Name: St✓E f,1TMC"F-0 Title: <br />2. Name: <br />3. Name: <br />Title: <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: <br />Title: CorwL,r <br />Date: 12 -i& -o,7 <br />DO NOT WRITE BELOW THIS LINE <br />R.E.H.S. Application Approval: Date: J-11-V-6211,Expiration Date: 17,13 1 / Date Paid: (2/ J l 0 7 Cash o heck #: (p0 Received By: L� <br />EHD 45-01 <br />10/02,07 FAD 0 oa�f3� <br />