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r <br /> it- <br /> SAN JOAQUIN COUNTY r 7/ <br /> X21 ENVIRONMENTAL HEALTH DEPARTMENT <br /> r. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd <br /> gt1�o�ia <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,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 A.PPROV <br /> Medical Waste Management Program , <br /> 1868 E. Hazelton Avenue, Stockton, CA 95205-6232 <br /> Medical Waste Hauler Information <br /> ❑ New Renewal <br /> Medical Office/Business Name: e hahFy & i t We-4 eat--h,ll'IL. clA -FDcas +KA 1+1) <br /> Medical Office/Business Address: ISO 6. Murch L"—e i S61-3p-A <br /> ��tDc k-12m (,A 952-)Q <br /> City State Zip Code <br /> Contact Person: :i <br /> Phone Number: 2 y}Z 4669 <br /> Storage Facility Name: Re.habFb"& lipmf.. w1k4,1yX X6+4 �GuS ffaLI`{-k <br /> Storage Facility Address: 1503 E. Mar(-K LaKH, Cu i+e. A <br /> <�ftc,k-tph (A °152.1 O <br /> City State Zip Code <br /> Permitted Treatment Facility Name: S-i2Yi C C I <br /> Permitted Treatment Facility Address: LA 135 Vj ARWP" <br /> `Fi-f sn.0 0+ q 3 ZZ <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste(I.f more than 3,attach info): <br /> 1.Name: P attiac h2M Title: <br /> 2. Name: Title: <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 records shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: �1N111YI d A Date: 12j l 20 z <br /> Title: C2Cv11VIV11VlIS'i1'0�ti ftSSiS-tAl'lt- <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: -.Q 4 — gnnk� Date: k7- /�l /jam <br /> Expiration Date: Date Paid: l.Z /02 d / Id— Cash or 4ec : Received By: <br /> EHD 45-01 <br /> 11/19/08 <br />