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SAN JOAQUIN COUNTY PAY <br /> g RECEIVED <br /> '--, ENVIeNMENTAL HEALTH <br /> 304 East Weber Avenue, 3rd Floor, Stoc on 9 - 08 <br /> • <br /> Telephone: 209 468-3420 Fax: 209 468-343 s v.or / d DEr' ZQ04 <br /> a F o SAN JOAQUIN COUNTY <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEM� I�NMENTAL <br /> H DEPARTMENT <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 $70.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 304 East Weber Avenue, 3 Floor, Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> ❑ New Renewal <br /> Medical Office/Business Name: Hospice of San Joaquin <br /> Medical Office/Business Address: 3888 Pacific Avenue <br /> Stockton CA 95204 <br /> City State Zip Code <br /> Contact Person: Donald E Gallup <br /> Phone Number: 209-957-3888 <br /> Storage Facility Name: Hospice of San Joaquin <br /> Storage Facility Address: 3888 Pacific Avenue <br /> Stockton CA 95204 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Steri cycl e, Inc. <br /> Permitted Treatment Facility Address: 1345 Doolittle Dr <br /> San Leandro CA 94577 <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: See Attached 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: a G Date: 0pcpmhpr 3, 2004 <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: / D <br /> tt: <br /> Expiration Date:�/ �/ / Date Paid: / / Cash or eck aa� o� Received By:�/ <br /> EHD 45-02-001 <br /> 10/7/2003 <br />