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SAN JOAQUIN COUNTY <br /> FILE <br /> EIONMENTAL HEALTH DEPARTI NT <br /> 600 East Main Street, Stockton, CA 95202-3029 = <br /> - � 1 <br /> ccq ;P Telephone:(209)468-3420 Fax.(209)468-3433 Weh:www.sigov.org/ehd SAN X007 <br /> F 0 <br /> 42� <br /> H FNVjgO 01 C0UN7y <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIONtTH�FPgR M�N� <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$72,00 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 /> ❑ New ❑ Renewal <br /> Medical Office/Business Name: L� 1��` v/�'d'Yl:f <br /> Medical Office/Business Address: <br /> City State Zip Code <br /> Contact Person: t// a-) <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: D. <br /> d�t �O —� S'' <br /> City Sta e Zip Code <br /> List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): <br /> 1. Name: /AtJf.O /—/'10 GU Title: /�/O C7 AJ 11-2 <br /> 2. Name: :.,,e-r2/z. � �rz 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 waste records shall be kept on file at generator's or health care professional's facility. <br /> A licati Si ature: <br /> pp gn Date: <br /> Title: <br /> DO O )�,"j ELOW T IS VIN q/q(b'�l <br /> R.E.H.S. Application Approval: Dat <br /> Expiration Date: (2/ 31 / Date Paid: - heck .�_ Received By: V� <br /> EHD 45-01 <br /> 10/02/07 <br />