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SAN JOAQUIN COUNTY <br /> EIWONMENTAL HEALTH DEPARAWT <br /> 600 East Main Street, Stockton,CA 95202-3029 E e <br /> ' Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ " <br /> `�F 2®08 <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION QUIN COUNT <br /> NMEMAL <br /> ni I)EP,(�[{ <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Management Act",the toll <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$77.00 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 /> ❑ New dRenewal <br /> Medical Office/Business Name: - b1V <br /> Medical Office/Business Address: <br /> _I1VDC 0L C1 O N LN 12,&— <br /> C <br /> ityState -Zip Code <br /> Contact Person: ty-i L.. yet y L Aft TL k Y Su PE Y V1 <br /> Phone Number: <br /> Storage Facility Name: 22,q C <br /> Storage Facility Address: ,/A <br /> City State Zip Code <br /> Permitted Treatment Facility Name: ShARPS PA M,PU <br /> Permitted Treatment Facility Address: P&ULA to, <br /> �1T b iAGS TX °a 3 <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: E C 1 L D Title: <br /> 2. Name: Title: <br /> 3. Name: Title: <br /> A copy of this exemption and a trackingd ent shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical wast'` reco ds 11 be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: Date: <br /> Title: �[ <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: <br /> Expiration Date: l / 1 / Date Paid: Cash or Check#:Vb Received By: <br /> EHD 45-01 <br />