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SAN JOAQUIN COUNTY <br /> ENvONMENTAL HEALTH DEPARTMEIR <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> APPLICA'T'ION FOR A LIMITED UANTITY 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. <br /> Please complete the information below and mail with $77.00 fee to: l <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program EC <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> SAN JOAQU <br /> Pd'd RO N M V N-TAL <br /> Medical Waste Hauler Information HES.THDEpOTMERd1 <br /> ❑New Renewal <br /> Medical Office/Business Name: 0 (t Clrt r`l� <br /> Medical Office/Business Address: l �'�- e .ic <br /> 7 T12 �m a <br /> City State Zip Code <br /> Contact Person: 5-Kf <br /> Phone Number: C T?,2- -02,Tz" <br /> Storage Facility Name: &S 61 <br /> Storage Facility Address: ey t` 't c- <br /> ✓-� <br /> cs t`a C11, CA-- <br /> City / State Zip Code <br /> Permitted Treatment Facility Name: 1 ® �- <br /> Permitted Treatment Facility Address: 13 -1) C,(r (r- <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: A Uf Title: <br /> 2. Name: r e Title: <br /> 3. Name: Title: <br /> A copy of this exemption and eking document shat be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical waste cords shall be pt on file at generator's or health care professional's facilPy. <br /> Applicant Signature: Date: �Z' ZO <br /> Title: �a " <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: / / to <br /> Expiration Date: / / Date Paid: Cash o Chec T Received By: <br /> EHD 45-01 <br />