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p4U1" SAN JOAQUIN COUNTY <br /> y r:: ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> q �P (209)468-3420 Fax: (209) 464-0138 Web:www.sjgov.org/ehd <br /> <<F o.. <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, transports 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 or a <br /> 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 to <br /> 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 APPROVE <br /> Medical Waste Management Program <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Medical Waste Hauler Information <br /> ❑ New ❑ Renewal <br /> Medical Office/Business Name: 0S WdNrSS <br /> Medical Office/Business Address 2glfo D&c"U TJW -WIVE I IDD <br /> C EI(LI� a� D�IJ 1.1 <br /> OD � 3� <br /> City State Zip Code <br /> Contact Person: IDMIC, tJ <br /> Phone Number: D61C.EEKC1)S ►J I:SS . Cola t'30I g2LO-600SC1 <br /> Storage Facility Name: S ly(!-�S L"��1�IeUN I Cly S�eVtCES I KIC- <br /> Storage Facility Address: -151C <br /> City State Zip Code <br /> Permitted Treatment Facility Name: SHAfLpS ENI It2(�J l.l�hlfi41_ 5 BVI.CZS INC <br /> Permitted Treatment Facility Address: <br /> 0 A6:F- <br /> City State Zip Code <br /> List all employee npmes and titles authorized to transport the medical waste (If more than 3, attach info): <br /> 1. Name: LNAL l I 1�1-- Title: <br /> 2. Name: WO 1-HOSOCl Title: 12� <br /> 3. Name: ►ti LUL✓ke(L- Title: EV. <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In addition,all copies of <br /> medical waste records shall be kept on file at generator's or <br /> health care professional's facility. <br /> Applicant Signature: S �%GGfi� v�7�' � I Date: <br /> Title: Se wsz-r <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: �L, Date: t�Z/6/I— <br /> Expiration Date: 12. /'JI / 13 Date Paid: 0 J / ?-Cash or e : ;2 ZSll Received By: <br /> EHD 45-01 5/2/12 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />