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SAN JOAQUIN COUNTY <br /> 2 2 <br /> EN4&ONMENTAL HEALTH DEPARTAWIT <br /> �. 600 East Main Street, Stockton, CA 95202-3029 Copy <br /> Telephone:(209)468-3420 Fax:(209)468-3433 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, 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. PAYMENT <br /> Please complete the information below and mail with $77.00 fee to: RECEIVED <br /> San Joaquin County Environmental Health Department DEC 10 2009 <br /> Medical Waste Management Program SAN JOAQUIN COUNTY <br /> 600 East Main Street Stockton CA 95202-3029 :yVIRGNMENTAL <br /> , , f_r;.i r;-r p�:PAATMENT <br /> Medical Waste Hauler Information <br /> ❑ New Renewal <br /> Medical Office/Business Name: OS 1. 0 <br /> Medical Office/Business Address: <br /> C'ty State Zip Code <br /> Contact Person: ,�� .� g r rows <br /> Phone Number: P 9 <br /> Storage Facility Name: fC, 0 5� . O Lw <br /> Storage Facility Address: 3009 T _` <br /> 5 !Ju C -5, <br /> C, State Zip Code <br /> Permitted Treatment Facility Name: -�4,f v- l o e Vt c- <br /> Permitted Treatment Facility Address: <br /> SFt., -,i C.'W" C <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste (If more than 3, attach info): <br /> 1. Name: Title: <br /> 2. Name: ? G/ Title: <br /> 3. Name: rtle: <br /> A copy of this exemption and a track4w ocument shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical waste ecords shall be kep n file at generator's or health care professional's facility. <br /> Applicant Signature: 6 �� Date: �� 7 <br /> Title: "V CC-fei vt cZ e -4-- <br /> DO <br /> 4'DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: ✓ <br /> Expiration Date: -li/ / M Date Paid: / D /i9j_ Cash oICheck : Received By: <br /> EHD 45-01 <br />