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Its <br /> Q*_ iV/ZUUd xUZ 14:11 rax ZV maa bdu Aaw wljvu4f VV& <br /> SAN JOAQUIN COUNTY <br /> X ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 L.13 7(08 <br /> 7Weoome:(209)468-3420 Fax.,(209)448-3433 Web. www.sjgov.org/ohd <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTlWJ1'i*/'WWCF$ <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 ww1c,transport less <br /> than 20 pounds of medical wash 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 Doewmem if the generator or parent organization is a small quantity generator not required <br /> to register pursuant to Chapter 4. <br /> Please complete the Wfomation below and mail with$72.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Managomont.Program <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Medical Waste Hauler Information <br /> [3 New Renewal <br /> Medical Office/Business Name: <br /> Medical OfficeBusiness Address: <br /> Ci State Zip Code <br /> Contact Person: <br /> Phone Number: <br /> Storage Facility Name., _'<�rfm Li=As <br /> Storage Facility Address: <br /> City state Zip Code <br /> Vlr%I 1AV0 — A% I <br /> Permitted Treatment Facility Name- <br /> Permitted Treatment Facility Address:' <br /> 7., <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 /> 1,Name: ,-"ILA 17qLA10P_=__ Title: <br /> 2.Name:_VMYtfl I — Title: <br /> 3.Name; 9-MMY11- U+WIQ Title: <br /> A copy of this exemption and a tracking document SM11 be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical waste records shall he kept on ate at generator's or hes"care professional's facility. <br /> Applicant Signature: Date: . <br /> f <br /> Title: < <br /> DO NOT WRITE BELOW THIS LINE <br /> &E.H.S,Application Approval: Date: <br /> Expiration Date: 0,/ ✓//_f2Date Paid: l &Cash cr Check#, 92g2Rece1vzd By, <br /> Z0/Z0 39Vd Z86086LSZG LZ:90 900Z/9Z/Z0 <br />