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,< c <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> 3 <br /> APPLICATION FOR A LIMITED QUANTITY 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, transports 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 or a <br /> 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 to <br /> 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 APPROVED ' <br /> Medical Waste Management Program I <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Medical Waste Haullerinformation <br /> ❑ New Renewal <br /> Medical Office/Business Name: �OCl1S }YICe , <br /> Medical Office/Business Address I'a03 E. MArcH lune. &i-w-P% <br /> 4S:tC4 -tvv\ CA 9 S 21 n <br /> City State Zip Code <br /> Contact Person: <br /> Phone Number: <br /> Storage Facility Name: 4kaA,inc. <br /> Storage Facility Address: JC <br /> D3 6• MArchlLtlnZ�cSui 12 �E c 1=tD C�} gS21 DCity State Zip Code <br /> Permitted Treatment Facility Name: 5ftVjCqdj,jfl(-- <br /> Permitted Treatment Facility Address: 14135 w. �S►>ii 2YlV�, <br /> -1rr vlo GA 9342,1- <br /> city <br /> X22City 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: C4 6oAY1•e.l I P-N Title: �Z T ✓ _ <br /> 2. Name: MiTitle: isy-"Ayrsp" <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 addition,all copies of <br /> medical waste records shall be kept on file at generator's or health care professional's facility. <br /> A p p I i c a n t S i g n a t UtLAW412��t Date: PAYMENTTitle: o-W J <br /> "�oEiVED <br /> DO NOT WRITE BELOW THIS LINE DEC 30 2013 <br /> SAN JOAQUIN COUNTY <br /> REHS Application Approval'��� < �� - Date: 1Z/.5n/j3EALTN DEPARTMENT <br /> Expiration Date: Date Paid: / \5 Cash or eck# 3992- Received By: <br /> EHD 45-01512112 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />