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/?` `•o� JAN JOAQUIN COUNTY <br /> E IRONMENTAL HEALTH DEPART NT PAYMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 RECEIVED <br /> c. Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> {tFpR�/ DEC 11 2009 <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIOTJAN JOAQUIN COUNTY <br /> ENTTVIRpO�NMENTAL <br /> To qualify fora"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management Ac1tt E�Athe tol�owing T <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 /> 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 /> p New Renewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: . <br /> City - State Zip Code <br /> Contact Person: <br /> Phone Number: ,i - ?'/ <br /> Storage Facility Name: 25l1i� Ale V ,�/ �✓ <br /> Storage Facility Address: ' <br /> l <br /> City State Zip Code <br /> Permitted Treatment Facility Name: L <br /> __Permitted- Treatment Facility Address: r_, <br /> ti <br /> � — <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: 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 medicalw records shall be ke n file at generator's or health care professional's facility. <br /> Applicant Signature: Date: --1 � <br /> Title: n a� A2 ffze <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: <br /> Expiration Date: / / Date Paid: ,2-/ �/ Cash or Check 3\ g 3 Received By: <br /> E1-ID45-01 <br /> w <br />