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QU 11V %V/SAN JOAQUIN COUNTY ! ; <br /> y ARONMENTAL HEALTH DEPART NT <br /> 600 East Main Street, Stockton, CA 95202-3029 L';"'� <br /> C1. P • Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd SAND `��) <br /> ENV�AQU/N co <br /> NAI u <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIOLTN HEPAR MFN <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 ¢' <br /> to register pursuant to Chapter 4. �1 l (1_= !J <br /> Please complete the information below and mail with$72.00 fee to: APR x 4 2008 <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program " V1RU .'64F.NT HEALTH <br /> 600 East Main Street, Stockton, CA 95202-3029 'ERMI T/SERVICES <br /> Medical Waste Hauler Information <br /> ❑ New ❑ Renewal <br /> Medical Office/Business Name: �all <br /> Medical Office/Business Address: <br /> CityState Zip Code <br /> Contact Person: -D14411 O ',/n j <br /> Phone Number: <br /> Storage Facility Name: / <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: i 3S WeSf Sw -F XJ2. <br /> ►'-,re5n CA -q 3-Za r <br /> StZe Zip Code <br /> List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): <br /> 1. Name: 4 Ai/f- ALJ/ /'0 CU Title: <br /> 2. Name: —e-41Z Title: <br /> 3. Name: .p 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 w�ste records shall be keton file at generator's or health care professional's facility. <br /> Applican Signature: Q. Date: <br /> Title: -5K;;5- <br /> ' <br /> J <br /> DO O ELOW T IS IN �(�Ib <br /> R.E.H.S. Application Approval: 'V� Date. <br /> Expiration Date: /Z/ 31 /0Date Paid: 2-10 ? heck . -4 Received By: _ <br /> EHD 45-01 <br /> 10/02/07 <br />