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�utN� <br /> SAN JOAQUIN COUNTY <br /> E1&ONMENTAL HEALTH DEPART& <br /> - y 304 East Weber Avenue, 3`d Floor, Stockton,CA 95202-27 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.or pj <br /> SFO¢ <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 $70.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 304 East Weber Avenue, 3`d Floor, Stockton,CA 95202 <br /> Medical Waste Hauler Information <br /> ❑ New [ Renewal <br /> Medical Office/,Business Name: i D <br /> Medical Office/Business Address: Lit) 7b � lco <br /> 16 <br /> City State Zip Code <br /> Contact Person: <br /> Phone Number: C>c;--` 1,--2 ()a <br /> Storage Facility Name: 1G� . <br /> Storage Facility Address: /U <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Li sit <br /> Permitted Treatment Facility Address: <br /> City State Zip Code <br /> List all employee names and title ,uthorized to transport the medical waste(If more than 3, attach info): <br /> 1. Name: Title: <br /> 2. Name: Title: <br /> 3. Name: Title: <br /> A copy of this exemption ajwast <br /> ljg ment shall a in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medir c rds shall be ke on file at generator's or healthcare professional's facility. <br /> Applicant Signature: Date: —��,—(� <br /> Title: <br /> DO N T W ITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: Z/ 3 /D <br /> Expiration Date:�/�/QS Date Paid: Cash o Check#: S Received By: <br /> EHD 45-02-001 <br /> 10/7/2003 <br /> • <br />