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925W 0382 20 p.m. 07-18-2008 2/2 <br /> 07/38/2008 FRT 15: 42 FAX 2094683433 SJC EHD ja002/002 <br /> A <br /> SAN JOAQUINCOUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> TelePlione.-(209)468-3420 Fax. (209)468-3433 Web.-www.sjgov.org/ehd <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTICK i i*/Sl,I-P.lal 1"N FP1 <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$72.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> ti <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Medical Waste Hauler Information /4JUL 212U013 <br /> 0 New *Renewal '% - SAN JOAQUIN COUNTY <br /> Medical Office/Business Name: ENVIRONMENTAL <br /> HEALTH DEpA4�CTMENT <br /> Medical OfficeMusiness Address: ILIMLA <br /> ei rat <br /> Contact Person: Zip Code <br /> Phone Number: <br /> X Storage Facility Name: )A <br /> p( Storage Facility Address: <br /> Cit <br /> State Zip Code <br /> Permitted Treatment Facility Name: 94 <br /> Permitted Treatment Facility Address. <br /> A05 <br /> ,)e City X State )C Zip Code <br /> List all employee names and titles authorized to transport the medical waste(If more than 3,attach info): <br /> I. Name: IL Title: <br /> k <br /> 2. Name: y I <br /> 3. Name: Tide: <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: , <br /> Title: Date: -)n <br /> DO N9WRI ELOW THIS LINE <br /> R.E.H.S. Application Approval::41- <br /> ---.Date: <br /> Expiration Date: Oenetledo-r <br />