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0 '911 <br /> 2094758356 ASERACARE • 02:: 5p.m. 04-03-2012 3/4 <br /> 04/03/2012 09:19 2094640138 ENVIRONMENTAL HEALTH PAGE 03/03 <br /> SAN JOAQUIN COUNTY <br /> �,•�„�/F+.per FIL <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> { <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> (209)468-3420 Fax.(209)464-0138 Web:www_sjgov.org/ehd <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,transports 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 targe quantity generator or a <br /> 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 to <br /> 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 /> Madlcai Waste Management Program <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Medical Waste Hauler Information <br /> D New U Renewal <br /> Medical OfficelBusiness Name: ,!5jPj C <br /> Medical Office/Business Address <br /> c <br /> ity State Zip Code <br /> Contact Person: <br /> Phone Number: �7�i 2 3 V <br /> Storage Facility Name: 71 24A <br /> Storage Facility Address: 1 gy I-A Ae 2n 5:2 <br /> City State Zip code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: <br /> pw <br /> CRY state zip coo* <br /> List all employee names and ti auth rued to tranlooq the medical waste(If more than 3,attach info): <br /> 1. Name: _ Title: <br /> 2, Name: Tide: <br /> 3. Name: Title: <br /> A copy of this exemption and a tracking document shall be in employee's poaasssion at all times while tra rung medl 1 Ants. in addition,all copies of <br /> medical waste records shell ba kept on file at generator's or health caro professioners faclllty. <br /> Applict Signat re: Date: <br /> Title: <br /> DO NOT WRITE 13ELOW THIS LINE <br /> REHS Application Approval; : _ Date: 11-142, <br /> Expiration Date: l�I 10-Date Paid: I 1L? 112-c-ash r Check#: D�37J(0 �eceived By: <br /> EHO 45-0111120111 APPLICATION FOR A IMrMO QUANTITY HALIuNG EXEMPTION <br /> " 11kI;L1 <br />