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tlfty� <br /> }° o SAN JOAQUIN COUNTY <br /> � ? NT <br /> E ONMENTAL HEALTH DEPAR �-, '.'� 3 E:Cg l <br /> , 600 East Main Street, Stockton, CA 95202-3029 VD <br /> Telephone: 209 468-3420 Fax: 209 468-3433 Web:www.s ov.or ehd G �,; <br /> P ( ) ( ) �g g/ <br /> SANJOAcaU,N ooUNTy <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEP rUn�E <br /> -rAj <br /> EPARrt4 r <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 /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ❑New *enewal <br /> Medical Office/Business Name: Addus Healthcare <br /> Medical Office/Business Address: _,( e, t ,cj , _ <br /> modekj&w <br /> City _ 9 Zip Code <br /> Contact Person: °, , ..pc... n, <br /> Phone Number: <br /> l <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> cue <br /> City Modesto, <br /> t 95355 Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: <br /> 6 / <br /> 4. <br /> City State Zip Code <br /> List all employee names- nd titles authorized to transport the medical waste(If more than 3, attach infq): <br /> 1. Name: <br /> ame /__j...a, Title: <br /> 2. Name: <br /> 3. Name L - Title:'_`") <br /> d <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.w to records shall be kept on file at generator's or health care professional's facility. <br /> Applicant atum, z_a Date: <br /> Title: — <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval- Date: OV461-6-9 <br /> Expiration Date: 1 / d / Date Paid: Cash o Check Received By: <br /> EHD 45-01 <br />