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WrI.L014uva RAI LUZ 15 YAK 2094683433 SJC REID 12002/002 <br /> O <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT co <br /> 600 East Main Street,Stockton,CA 95202-3029 F --13' <br /> Telephone:(209)468-3420 Fax. (209)468-3433 Web.-www,sjgov.org/ehd <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPT16*tirli,; <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 /> 9CUMtOr 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 /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Medical Waste Maul,e.r Information <br /> 0 New *Renewal <br /> I <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: (TIOXII-AXIL <br /> --- 1 <br /> Cit <br /> Contact Person: State Zip Code <br /> Phone Number: <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> O <br /> 'Sity State Zip Code 00 <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: <br /> 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 />