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r <br /> 4748356 aseracare 0018 p.m. 02-09-2010 1 /2 <br /> 1T <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> '�' •J - SAN J1.7AC�UIN COUNTY <br /> Telephone: 209 468-3420 Fax 209 468-3433 Web:www.s ov.or ehd <br /> �a�iFo.-4/ P ( ) ( Jg ENV►fit7NMENTAI <br /> HEALTH DEPARTMENT <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: /"' e _l.S.�l�e 1&0la <br /> , <br /> Medical Office/Business Address: .2529 W. March Lane, Suite 101 <br /> Stock_ton_, (1 tl[ 20 7 <br /> State Zip Code <br /> Contact Person: Sabira _Cajpe <br /> Phone Number: (2093 47443-0 <br /> Storage Facility Name: _ ---- <br /> Storage <br /> Storage Facility Address: same as business address <br /> City State Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste(If Rr;than 3,attach info): <br /> 1.Name: Title: KlV <br /> 2.Name: CL Title: <br /> 9& <br /> 3.Name' Title:SM <br /> A copy of this exemption and a trac ting document shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical A.ste records shall be kept on file at generator's or health care professional's facility. <br /> Applicant SignatureQDate: 2j— a 11 Q <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: , Date: ?j/ 14 /f6 <br /> Expiration Date: �/�/ 10 Date Paid: k'a./ 3b/ 6 I C7ts1�-etCheck#:pbg 9 ���g Received By: <br /> EHD 45-01 <br /> 11/19/08 <br />