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01 <br /> It f <br /> SAN JOAQUIN COUNTY <br /> E10ONMENTAL HEALTH DEPART10T �e' El <br /> �. 1 `� <br /> MVED <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> � p Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov. ®E 1 2008 <br /> Ip. <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXE PTIO� ENVIRONMENTAL <br /> �iEALTH UEppR-rMENT <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: <br /> Medical Office/Business Address: <br /> ity State Zip Code <br /> Contact Person: <br /> Phone Number: <br /> Storage Facility Name: c a 2 L <br /> Storage Facility Address: 9 ; <br /> City State Zip Code <br /> Permitted Treatment Facility Name: _ ® &Cg=l(' O A P <br /> Permitted Treatment Facility Address: 1345 Doolittle Drive—Per Rosie Ybarra <br /> San Leandro CA 94577 <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: Title: <br /> 2. Name: K V0, f ACt k F Title: air\_.n <br /> 3.Name: Title: <br /> A copy of this exemption and a t cking ocument shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical w to rec ds sh 1 ept on file enerator's or health care professional's faci <br /> Applicant Signature: Date: <br /> Title: <br /> DO NOT WRITE BE OW THIS LINE <br /> R.E.H.S. Application Approval: Y ® - - Date: _ /Cq <br /> Expiration Date: / / Date Paid: /2..l 01 /O Cash or Check Received By: <br /> EHD 45-01 <br />