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SAN JOAQUIN COUNTY <br /> r ` E ONMENTAL HEALTH DEPART�T <br /> a 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd JAN 2 p 2010 <br /> i'o <br /> j QUI <br /> APPLICATION FOR A LIMITED QUANTITY HSAN AULING EXEMP��rTDRoONMEN COUNrq�n" <br /> SPAR-rA4E <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: [pvSan 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 /> ❑ New Renewal <br /> Medical Office/Business Name: 4m--e r t cal `'q_e�,L'u,_, &.3 Ncy, �-c <br /> Medical Office/Business Address: Y U o S , 7�_e; -70 Q Y _P_/ L-...-c? <br /> S(-u c.K fytn, ? S-)103 <br /> City State Zip Code <br /> Contact Person: G Ice I j­e a e a r-,- �(u.!� <br /> Phone Number: a c - 9 f- S&/ 2- g S 3 9 97 <br /> Storage Facility Name: /4m,"1 r A-rl- -M-e C(t cu- spCm <br /> Storage Facility Address: i f d 0 S. f—e S n a /}v e it ' <br /> city I State Zip Code <br /> Permitted Treatment Facility Name: 9 "I c LI CIO, TC . <br /> Permitted Treatment Facility Address: _ i 3 5 iJ s-w,r a v_,e rL"_Q_ <br /> 7:�-4-S n.y C ct. -7 >, 7 d-JA— <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: 3-e-e, C{ 4 i c 1-, «Q ccs Title: <br /> 2. Name: Title: <br /> 3. Name: Title: <br /> A copy of Is exemption and a tracking document s all bei employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical waste re rds s 11 ke Itgenerator's or health care professional's facility. <br /> Applicant Signature: Date: <br /> Title: f vr� \ c_. <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: pL/ / <br /> Expiration Date: Date Paid: Cash Check#: D , Received By: its <br /> EHD 4s-o 1 <br />