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U <br /> �o co SAN JOAQUIN COUNTY <br /> _ z ENABONMENTAL HEALTH DEPART <br /> y < PAYMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 1\/FD <br /> `P Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgoi:o hC <br /> 4G/FpR , 2007 <br /> t APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIIJOAQUIN COUNTY <br /> tNVIRONMENTAL <br /> HEALTH DP <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management Act", t eo ing <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. <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 Hauler Information <br /> Q New Renewal <br /> Medical Office/Business Name: aS L E'- S <br /> Medical Office/Business Address: 3 eye 4 C <br /> City State Zip Code <br /> Contact Person: !Le-eve, <br /> Phone Number: _ 7,©R 9f7- 36?5gr <br /> Storage Facility Name: /r a <br /> Storage Facility Address: qtr <br /> 5E 6a <br /> City State Zip Code <br /> Permitted Treatment Facility Name: N � 1,G c e wt <br /> Permitted Treatment Facility Address: 3 o ✓- <br /> S c, t4 --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: :L-0—e d4 e- 4 e Title: <br /> 2. Name: Title: <br /> 3. Name: Title: <br /> i <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 wastr— <br /> shal a kept on file at generator's or health care professional's facility. <br /> Applicant Signature: 'l� G"� c� "`� Date: rZ �/ <br /> PP7 <br /> Title: V!®1`® e v;i% Nc7 <br /> DO N T WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: —Ll�lvl) <br /> Expiration Date: lz�/ 3/ /Date Paid: �2--/ \S / b1 -Gash Check#: Received By: <br /> EHD 45-01 <br /> 10/02/07 <br />