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" WN JOAQUIN COUNTY ,I <br /> u� r + <br /> -� ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202-2708 (, <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd 2006 <br /> SAN JOAOUI, OOiJNTy <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIONH ENVIRONMENTAL <br /> EALTH DEP'';RTWIENT <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. <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 /> 304 East Weber Avenue, 3`d Floor, Stockton,CA 95202 <br /> Medical Waste Hauler Information <br /> El New I,Renewal <br /> Medical Office/Business Name: oS <br /> Medical Office/Business Address: <br /> City State Zip Code <br /> Contact Person: �:;W—-P--d <br /> Phone Number: <br /> Storage Facility Name: ,vJ;E SCA 714n ao 1 Z`A <br /> Storage Facility Address: g2s 1�G�� '� NY e `A <br /> �Ci`ty State Zip Code <br /> .Permitted Treatment Facility Name: -:e <br /> Permitted Treatment Facility Address: \ - 4�5 S <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: 1:7e_ 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 waste records shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: Date: /fT 7 A <br /> Title: '01,r�- a <br /> �' ` <br /> DO NO WRITE BELLOW THIS LINE <br /> R.E.H.S. Application Approval: Date: <br /> Expiration Date: /3LI -Date Paid:�a/�_/ V�check#: aL 1 � Received By: <br /> EHD 45-01 <br /> 0'7/31/06 <br />