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c. SAN JOA C!,N COUNTY E ONMENTAL EALTH DEPAR*NTx �a <br /> '® 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehdRECEIVED <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTI _ 2008 <br /> SAN JOAQUIN co <br /> '� LT <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the "Medical Waste Manage AthM lowtng <br /> conditions must be met: H DEPART EN r <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$77.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ❑New Renewal <br /> Medical Office/Business Name: I'(- e <br /> Medical Office/Business Address: ` ' c_ (� <br /> g, C .'!�Z- ' <br /> C7�e <br /> State Zip ode <br /> Contact Person: Cl/ V1,fo 41$' <br /> Phone Number: 7" <br /> Storage Facility Name: a tZ- <br /> Storage Facility Address: 9>9 6 A C ,-e4 <br /> n 2 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: t - <br /> Permitted Treatment Facility Address: <br /> 7 <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: Title: <br /> 3.Name. 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 wa§te records sh a kept on file at generator's or health care professional's facility. <br /> Applicant Signature: Date: Z( <br /> Title: - <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: / <br /> Expiration Date: % L./ / Date Paid: / 0-2-10ir Cash or hec : f Received By: Lb <br /> EHD 45-01 <br />