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,oPqu1N. Fa • <br /> _ SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue, 3`d Floor, Stockton,CA 95202-2708 <br /> �:; `P• (209)468-3420•Fax:(209)468-3433 • Web:www.co.san-joaquin.ca.us/ehd <br /> A�I F ORa <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 F�V�T <br /> Medical Waste Management Program �EC O <br /> 304 East Weber Avenue, 3dFloor, Stockton, CA 95202 S 1 203 <br /> Medical Waste Hauler Information AN,!% Co <br /> EA <br /> ❑New Renewal H THOENRTT t <br /> MFNT <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: <br /> i C v <br /> CityL� , State Zip Code <br /> Contact Person: /�E!�' C� �-) 2 O <br /> Phone Number: p(p -f.2— D,-2- <br /> Storage Facility Name: <br /> Storage Facility Address: J 1 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: <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: V 1 Title: - G / U 1 n . <br /> 2.Name: Title: <br /> 3. Name: Title: (j) 0"T'1-1-77 <br /> A copy of this exemption and a ing document sh 1 be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical to ecords shall be e t on file at generator's or health care professional's fac ity <br /> Applicant Signature: Date: <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: -L/-I / <br /> Expiration Date: _4; lb Date Paid: 1� /�/�_Cash or Check#: �--F� Received By: <br /> EHD 45-02-001 <br /> 10/7/2003 <br />