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/ F, A ^v <br />PAYMENT JOAQUIN COUNT <br />s �r <br />N, fi:< WANMENTAL HEALTH DEPWTIVT RECEIVE) <br />• :.- 304 East Weber Avenue, Yd Floor, Stockton, CA 95202-2708 <br />(209) 468-3420 • Fax: (209) 468-3433 • lVeb: www.co.san-joaquin.ca.us/elidJAN 3 0 2004 <br />F o cs <br />APPLICATION FOR A LIMITED QUANTITY HAULING EXEM�N NP MENTAL <br />COUNTY <br />EARTMENT <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 />I . 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 <br />Medical Waste Management Program 002A, <br />304 East Weber Avenue, 3a Floor, Stockton, CA 95202 Medical Waste Hauler Information <br />❑ New VRenewal <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 />City d <br />Sate Zip Code <br />�• AF y <br />57-02720d ✓ wa <br />0 <br />city <br />S A&44 <br />State <br />Zip Code <br />� A V Mate Zip Code <br />List all employee names and titles authorized to transport the medical waste (If more than 3, attach info): <br />1. Name: �%i/l�' +�✓r�,✓/� /�% Title: <br />2. Name: s y <br />3. Name:�6aleu .JGTitle: <br />/-�_/_;� 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 waste records shall be kept on file at generator's or health care professional's facility. <br />Applicant Signature: D <br />Title: <br />ate. <br />DO NO WRITE BELOW THIS LINE <br />R.E.H.S. Application Approval: <br />ate: <br />Expiration <br />Expiration Date: L�/ ( 10,174 Date Paid: �/ �Q/ t%� Cash or eek # <br />-� Received By: <br />DID 45-02-001 <br />10/7/2003 <br />