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e <br /> 11/09/2005 13:37 2094683433 EHD PAGE 02 <br /> SAN JOAQUIN COUN'T'Y <br /> = ENVIR.ONAENTAL MALTH DEPARTIVMNT <br /> 304 East Weber Avenue,3"d Floor,Stockton,,CA 95202-27138 . <br /> (209)469-3424•Fax:(209)458-3433• Web:wwwr,co.san:joaquiin.ca.uslehd <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 mustbe met: <br /> The generator or health care professional generates IM 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 dile one of the following: <br /> 1. Medical Waste Management Plan if the generator or parent organization i5 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$70.00 fee to: <br /> San Joaquin-County-Environmental Health Deparft=t <br /> Medical Waste Management Program <br /> 304 East Weber Avenue,and Floor,Stockton,CA 95202 <br /> Medical Waste Hauler Information <br /> �ew [I Renewal <br /> Medical Offiice/Susiiness Name: <br /> Medical Office/Business Address: w fan Je- 5� <br /> errs n�c.� <br /> City . State Zip Code <br /> Contact Person: <br /> Phone Number: <br /> Storage Facility Name: ;�2r i c ct <br /> Storage Facility Address: <br /> Ci State zip Code <br /> Permitted Treatment Facility Name: u 6t X <br /> Permitted Treatment Facility Address: <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.Hams: ti -�-�e_ t <br /> E~V N Title: �6L.� <br /> 2.Name: L I� Title- <br /> 3.Name: ti -wict o+I►10 LV 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 was cords shall be pt off file at generator's or health care professional's facility. <br /> Applicant Signature: ✓ Date: <br /> Title: e s a <br /> DO r OPT WRIT LOW THIS LINE <br /> R.E.H.S.Application Approval: ]Date: L /,-/ <br /> / 1 / bate Paid 1. / / Cas er Check#- �3 C Received�y: <br /> Expiration Date: � <br /> �c+n sc(%1-AM 1 teK <br /> 2/T 02GTOT60TI7 -1aS a.100142�TpaH mTx1DJ4 Nd Ft7: VO 9002-TT-A0N <br />