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SAN JOAQUIN COUNTY F1L4AcjjW Y <br /> ?'S' "`-,a° 's ENVIRONMENTAL HEALTH DEPARTMENT <br /> �:: .;, .;:. FEB 0 5 <br /> 600 East Main Street,Stockton,CA 95202-3029 2009 <br /> SAN JOAQUIN COUNTY <br /> �ry.,,':;,�P <br /> Telephone. {209)468-3420 Fax. {209)468-3433 Web:www.sjgov.org/ehd <br /> ��~Ra,� H ENVIRONMENTAL <br /> NT <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 ,,Renewal <br /> Medical Office/Business Name: C-I" o+7 c+-tob.1- Fize 4DE'PAtt'7\ tAT <br /> Medical Office/Business Address: 47-5" A. G�t�o2aQv sem. <br /> ac.r--t04 CP. ': 5 ZOZ <br /> City State Zip Code <br /> Contact Person: 15co-F-r– �nct�o•.lr� <br /> Phone Number: --C2oob 9-s-} 85 Z8 - (off` ,0 e+ <br /> Storage Facility Name: ( <br /> Storage Facility Address: 1101 LJ, S A&&-- C:;)� <br /> 154nC-J- t>4 CA <br /> City State Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: <br /> �— CA- .Z-- <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: t3 EL\ht,.tit- Title: <br /> 2. Name: A -rrcucw-, co,_tiw� it s Title: <br /> 3. Name: 4 BP�MA c_A e,,,j Title: <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical to r c6rds shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signa Date: I ZA/o8 <br /> Title: Ca P-t--t c*lx I c kxs <br /> DO NOT WRI E BELOW THIS LINE <br /> R.E.H.S.Application Approval: Date: / '/ CFs <br /> Expiration Date: �J._L;Y__/Q Date Paid: / S / Cash or Check#: 0 S�10 b Received By <br /> RHD 45-01 <br />