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t`6o� SAN JOAQUIN COUNTY <br /> r 2 ENOONMENTAL HEALTH DEPARTNOT <br /> :{ YC���IIII inny <br /> �,. 600 East Main Street, Stockton, CA 95202-3029 � <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION-nFC <br /> 1 4 2009 <br /> SAN JOAQUIN COUNTY <br /> To qualify for a "Limited Quantity Hauling Exemption"pursuant to the "Medical Waste ManagemenIMg <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: <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 /> p New CRenewal <br /> Medical Office/Business Name: G, <br /> Medical Office/Business Address: JX"C.o <br /> 9v' d <br /> City State Zip Code <br /> Contact Person: <br /> Phone Number: a?Q 9- a 70x1".3" <br /> Storage Facility Name: �4r3 <br /> Storage Facility Address: .54-35 -S 60F OL <br /> i a4 904562Z 7 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: ' <br /> Permitted 'Treatment Facility Address: <br /> 37 <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: do/��ee4) Title: Q,d 1A1.S7rXff 7C j <br /> 2. Name: S Title: g/' kA-) <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 ords sh�bept on fil�atgene�rator's�orhealth care professional's facility. <br /> Applicant Si attire: Date:, r 1 <br /> Title: 4.04 <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: / /d <br /> Expiration Date: 0 Date Paid: 'Z / Iy /0 9 Cash or heck b_�_ Received By: <br /> EHD 45-01 <br />