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qu1 <br /> SAN.JOAIQUIN COUNTY <br /> r ti EN*ONMENTAL HEALTH DEPART <br /> a <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd <br /> �q�1FORN�P {G <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 PAY10E--N-V <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> D: 3 2007 <br /> SAN JOAQUIN COUNTY <br /> ❑ New Renewal ENVIRONMENTAL <br /> r HEALTH DEPARTMENT <br /> Medical Office/Business Name: L f t /fin f, crzt44'-.;1.A <br /> Medical Office/Business Address: J , <br /> .I eVV&LL d ()a [ 2 <br /> City State Zip Code <br /> Contact Person: 4e o <br /> Phone Number: z4 c.- s 8 i- (a S u 6-6 x I <br /> 'Q <br /> Storage Facility Name: Aiu14jbacV— z)o � <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: _ t�p, &noh IrIc <br /> Permitted Treatment Facility Address: r` , 'A AiiDl4i C. t Ir(.P V t <br /> Ci State Zi Code <br /> Cad I ,6V TY 7s-w 33 <br /> List all employee na es and titles authorized to transport the medical waste(If more than 3, attach info): <br /> 1. Name: 0,.. A4j4(_-�d G{. Title: <br /> 2. Name: Title: <br /> 3. Name: Title: <br /> i <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 Z <br /> a rec ds hall be kept on file at generator's or healthcare professional's facility. <br /> / 9 <br /> Applicant Signature: Date: IL`I/07 <br /> Title: <br /> DO NO WRIT BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: <br /> Expiration Date: /Date Paid: �af 3 /D-7 Cash heck#• /-7/0(atf Received By: L1� <br /> EHD 45-01 <br /> 10/02/07 <br />