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qu► <br /> o co SAN JOAQUIN COUNTY <br /> to ENSONMENTAL HEALTH DEPARTAT PAYMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 „ , FD <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd `(' 2 2008 <br /> �q��FORa�P SAN JOAQUIN COUNTY <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMP DEPART E <br /> EPgRrMENT' <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 Information <br /> Q New Renewal <br /> Medical Office/Business Name: trtJ ���L4 <br /> Medical Office/Business Address: VC/ <br /> CIA <br /> City State Zip Code <br /> Contact Person: �iyi vt r x Lr LlvIj kn, <br /> Phone Number: <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> City r State Zip Code <br /> �1 <br /> Permitted Treatment Facility Name: &WlN(AC, <br /> Permitted Treatment Facility Address: ti <br /> CCi <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: j W U Title: LV I\( <br /> 2. Name: fWv� 'CCA V of Ct Title: "d 4 <br /> 3. Name: kiaA (a M�V-j Title: W lh: <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: 1 Z' <br /> Title: 9 o1.a- v�Y <br /> 9 DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: <br /> Expiration Date: / / Date Paid: Castro eck# S 4(j Received By: [5 <br /> EHD 45-01 <br /> 10/02/07 <br />