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Adibb <br /> tic <br /> T <br /> 11/09/2005 13:37 2094683433 'iy' ■fa■nL�/�/��yyry� (/E''H'■D <br /> SAN <br /> COUNTY PAGE 0 <br /> ENVaONMENTAL HEALTH DEPARYMENT <br /> 304 East Wever Avenue,Vd Floor,Stockton,CA 95202-2708 <br /> (209)468-3424•F=-(709)468-3433• Web:n ww co.san joaquia.ca.us1ehd <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 Iess than 20 pounds of medical waste per week,transport Tess <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. Infomiation 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-CounV Enviroumental Health Department <br /> Medical Waste Management Progrcam <br /> 304 East Weber Avenue,P Ploor,Stockton,CA 95202 <br /> Medical Waste Hauler Information <br /> M/New Renewal <br /> Medical Clfficeflinsiness Name: <br /> MedicalOffzcusizuess Address: E{4n Ick�e< 5d <br /> City State Zip Code <br /> Contact Person: ^ r f <br /> Phone Number, c <br /> Storage Facility Nalene: <br /> Storage Facility Address: x <br /> x <br /> Ci State Zip Code <br /> Permitted Treatment Facility'Name: ' tt C14 6t x <br /> Permitted Treatment Facility Address: <br /> City State Zip Cade <br /> List all employee names and titles authorized to transport the medical waste(if mom than 3,attach info): <br /> 1.Narne: 'I) % AVIL4Lykt �Ltl N Title: i�c 1, cl LA <br /> 2.Name: L Title: <br /> 3.Name: 4 vmg toe+no 1_v Title: <br /> A copy of this exemption and at r2Cking document shall be in emptoyee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical was cords shall be pt otrfile at generator's or health care professional's facility. <br /> Otlp. '5I <br /> Applicant Signature: Date: <br /> Title: l'S d n r <br /> DO NOT WRIT LOW THIS LINE <br /> R.E.H.S.Application Approval: Date: (l! L/E� <br /> Expiration Date.�/31 f O�Date paid: 1A ! i'�C car Check#' S3 Cp Received By; <br /> can 3CMJV11 <br /> L7/T O2GTOT60TV -18S a.1100tl4TaaH WTXIDK Ltd 217: 170 9002-TT-AON <br />