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SAN JOAQUIN COUNTY <br /> N" EN ONMENTAL HEALTH DEPARTNOT <br /> ' 600 East Main Street, Stockton, CA 95202-3029 <br /> . Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ILE COPY <br /> \L 1 0 Rei• <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 $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 ARenewal <br /> Medical Office/Business Name: �p eA F l v-N V-CI �--1 <br /> Medical Office/Business Address: '3'f]D Fi:tlfz-fN uc"—{— <br /> LOCA i 9 15 24- j 0 <br /> City State Zip Code <br /> Contact Person: <br /> Phone Number: ()` ! 2-0 2- <br /> Storage <br /> Storage Facility Name: L ►a/(- S,/ S <br /> Storage Facility Address: " y Gt rte <br /> o C6A�, e,-- <br /> City State Zip Code <br /> Permitted Treatment Facility Name: �G�_1 <br /> _ <br /> Permitted Treatment Facility Address: as g 'Pao— D►Z._.__ e, <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. <br /> nfo):1. Name: 0S L; ib, rLTitle: <br /> 9 JtSf <br /> 2. Name: i-),40-n— �a_.�rno•;s r/a /l Title: A]/15- <br /> 3. Name: Title: <br /> A copy of this exemption and tracking document shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical a I hall be kept file at generator's or health care professional's facility. <br /> Applicant Signature: Date: (� <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: �"�. _ �., Date: 12—/-ZL/94 <br /> Expiration Date: t 2, / 3 1 /10 Date Paid: 1)--/ q /09 Cash o (41 Received By: -Zel� <br /> EHD 45-01 <br />