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1 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> « 304 East Weber Avenue,3rd Floor, Stockton,CA 95202-2708 <br /> ` f Telephone:(209)468-3420 Fax:(209)468-3433 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,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 111211 with$72.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 <br /> Medical Waste Hauler Information <br /> ❑New ARenewal hh <br /> Medical Office/Business Name: tit k., <br /> Medical Office/Business Address: q t <br /> City State Zip Code <br /> Contact Person: 0-i' LA <br /> Phone Number: <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> City State Zip Code <br /> .Permitted Treatment Facility Name: �" <br /> Permitted Treatment Facility Address: <br /> rf A/VV4IsW1® ���'�a <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: U` DSU Title: A0 , GVM <br /> 2. Name: �I/lwr►n _ Title: <br /> Title: thA <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: _ 161 Date: —�i ��`b <br /> Title: _�� ,,✓ <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: 4e Date: <br /> Expiration Date:–P—/ 3/ /-Q-Z Date Paid: 30/ 06 Cash o heck# �(a a 9 Received By: <br /> EHD 45-01 <br /> 07/31/06 <br />