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SAN JOAQurN COUNTY PAYMENT <br /> ENVIRONMENTAL HEALTH DEPARTMENT RECEIVED <br /> rd RECEIVED <br /> 304 East Weber Avenue, 3 Floor, Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd NOV 2 9 2006 <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION SAN JOAQUIN COUNTY <br /> ENVIRONMETAL <br /> HEALTH DEPARTMENT <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, 3rd Floor, Stockton,CA 95202 <br /> Medical Waste Hauler Information <br /> ❑New / enewal <br /> Medical Office/Business Name: YI <br /> Medical Office/Business Address: <br /> City State Zip Code <br /> Contact Person: <br /> Phone Number: <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> City State Zip Code <br /> .Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: <br /> City State Zip Code <br /> List all employee name d titles authorized to transport the medical waste(If more tha 3,�attach iZjlleK <br /> �/,�1. Name: � �6� 2 0 Title: �¢. 7L <br /> 2.Name: /�C`I J G� "T-.�c�Y2.0,., Title: m P _ _ <br /> 3. Name5h—OcA/700 011 7Y?&SG6? Title: <br /> A copy of this exemption and tracking doc went shall be in emplo e's possession at all times while transporting medicaTo "te. In <br /> addition,all copies of medica aste ords h b kept on file at a erator's or health care professional's facil ty. <br /> Applicant Signature: Date: 1 Z <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S.Application Approval: Date: <br /> Expiration Date: / / Date Paid: l/ l 021 l_Zo Cashheck# *65 3 Received By: (..it <br /> EHD 45-01 <br /> 07/31/06 <br />