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gg71 <br /> cA°u�N••c <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> ' 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> �qC%FOl2a`P (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <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 sma 11j,u2n,i n �_ of 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 <br /> Medical Waste Management Program APPROVE <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 �ifl <br /> ��--Medical Waste Hauler Information <br /> 11 New Rene arl t ll <br /> r ' <br /> Medical Office/Business Name: fb(m, +&t4) <br /> Medical Office/Business Address _IS03 iE. Mdrek h.! Svf It_ R <br /> St°`k t C.A 9SZlo <br /> City�nl <br /> Contact Person:/ •vW�I State Zip Code <br /> Phone Number: 100 44-2, OS- <br /> Storage Facility Name: eMOT:bWS -Htw }4fa,(+k �yic <br /> Storage Facility Address: ISb3 E. NlQVC12A D i,Sufi/} S(p�k tart, gs 7�o <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Cydf, IVA( , <br /> Permitted Treatment Facility Address: y 135 (�• ��} <br /> (,A- <br /> City State Zip Code <br /> List all employee names and titles aut prized to transport the medical waste(If more than 3, attach info): <br /> 1. Name: A,— cI2-Q_ &6 t 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 addition,all copies of <br /> medical waste records shall be kept on file at generator's or health care professional's facility. <br /> Applicant Sign ur Date: i Z) U[-m <br /> Title: mtAt PAYMENT <br /> RECEIVED <br /> DO NOT WRITE BELOW THIS LINE DEC 3O 2013 <br /> REHS Application Approval: `� ��J� ( Date: SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> Expiration Date: HEALTH DEPARTMENT <br /> EX <br /> p / / l� Date Paid: �L /30 / 5 Cash o Check : .3'19 3 Received By: <br /> EHD 45-01 5/2/12 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />