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jan-4o-aUU0 la :,tl em maxim nealtncare services 4U1j4/ /G--)44 G/J <br /> V <br /> SAN JOAQUIN COUNTY <br /> RONM <br /> ENTAL HEALTH DEPARTMENT <br /> .: 600 East Main Street, Stockton,CA 95202-3029 <br /> P. ov.or Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.s ehd <br /> ariFo��,• Jb � <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$72.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Medical Waste Hauler Informa <br /> c:10F)ly <br /> ❑ New )(Renewal <br /> Medical Office/Business Name: - 6i," 9,t1+k&-M sarv,'Ges <br /> Medical Office/Business Address: 1-77k- L i2 1Ka LQ <br /> S6CA 9 szcy� <br /> City State Zip Code <br /> Contact Person: j-; G' <br /> Phone Number: .2s� 4 7717 Z 7 <br /> Storage Facility Name: _l� W�j h 1'P ':�P me;c-eS <br /> Storage Facility Address: r d <br /> City State Zip Code <br /> Permitted Treatment Facility Name: -4ef'r —RqCa r- <br /> Permitted Treatment Facility Address: 2li/ <br /> r7 2 <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste(If more than 3, attach info): <br /> 1. Name: Title:- nr�W WC-S <br /> 2. Name: Title: .��rIch_ )-fa.mac" _ <br /> 3. Name: Anco-G Title: <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical waste records shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: Date: t 23 U 8 <br /> Title: Acc o Z. <br /> DO21d-"l <br /> T WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: �% zg/o <br /> Expiration Date: 17 <br /> / /�Date P / Z� O$Cash or Check#: Received By: <br /> EHD 4i-01 <br /> 10/02%07 <br />