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u r 4.pQ , <br />SAN JOAQUIN COUNTY 10 <br />ENVIRONMENTAL HEALTH DEPARTMENT R ,(j <br />jt <br />304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 <br />VEp <br />° Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sigov.org/ehd JAN 0 <br />� 9 2007 <br />APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIO", oNM ,U n, <br />To qualify for a "Limited Quantity Hauling Exemption" �Epp�� <br />q fy Q h' g p pursuant to the Medical Waste Management Act", the fo 0 <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 $72.00 fee to: <br />San Joaquin County Environmental Health Department <br />Medical Waste Management Program <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />Medical Waste Hauler Information <br />❑ New Renewal <br />Medical Office/Business Name: <br />Medical Office/Business Address: <br />Contact Person: <br />Phone Number: <br />Storage Facility Name: <br />Storage Facility Address: <br />.Permitted Treatment Facility Name: <br />Permitted Treatment Facility Address: <br />s i'DCK-arm C4 __q6Z07_ <br />City w _ n State Zip Code <br />1, <br />I-1ty State Zip Code <br />ulty 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: rim GIGS Title: <br />2. Name: 1!1 C2AA6UAa4AgM Title: <br />3. Name: 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 was records shalln file at generator's or health care professional's facility. <br />Applicant Signature: <br />Title: h re, TJ iV <br />Date: I <br />DO NO W11V1,j,,BELOW THIS LINE <br />R.E.H.S. Application Approval: Date: <br />Expiration Date:/ -3 /ate Paid: /�/Check #: 0 2 Received By: <br />EHD 45-01 <br />07/31/06 <br />