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SAN JOAQUIN COUNTY is RECEIVED <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />m i 1868 East Hazelton Avenue, Stockton, CA 95205-6232 N O 11 18 2014 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPT ki APRRiICE <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 $77.00 fee to: <br />San Joaquin County Environmental Health Department <br />Medical Waste Management Program <br />1868 E. Hazelton Avenue, Stockton, CA 95205-6232 <br />Medical Waste Hauler Information <br />❑ New 41Renewal <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 />City State Zip Code <br />City State Zip Code <br />List all employee names and titles authorized to transport the mc4ical waste (If more than 3, attach info): <br />1. Name: '5e -e- aA4tQ _-\-, _ t 4D 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, all copies of medical waste records shall be kept on file at generator's or health care professional's facility. <br />Applicant Signature: 6,1 Date: <br />Title: J /Qji . <br />R.E.H.S. Application Approval: Date: / <br />Expiration Date: / / Date Paid: / / Cash or Check #: Received By: <br />EHD 45-01 <br />11/19/08 <br />