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SAN JOAQUIN COUNTY <br /> PAYMENT <br /> X ENVIRONMENTAL HEALTH DEPARTMENT RECEIVED <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> DEC 9 2013 <br /> (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd cAN JOAQUIN COUNTY <br /> ,--NVIRONMENTAL <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION— ---4 DEPARTMENT <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 <br /> Medical Waste Management Program "PROVED <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 i a - <br /> Medical Waste Hauler Infor-mation <br /> 0 New 0 Renewal <br /> Medical Office/Business Name: !j we <br /> Medical Office/Business Address Of,ve, 13= <br /> (-,e,i Yvrn Cn ck",n M!) <br /> Contact Person: citk, o, ,- State- Zip Code <br /> Phone Number: kNA V&� nem,CoM <br /> Storage Facility Name: �-DV(ki PS -lw\N A C s ,in 0 b Tyl <br /> Storage Facility Address: C itis N\4102- %x 7 <"63 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: svc,"t?S se-f V V1 f- <br /> Permitted Treatment Facility Address: I < 1-4!j L1 �,)oe <br /> ('-C,X24A rA(A g, <br /> City , j- State Zip Code <br /> List all employee nmes and titles authorized to transport the medical waste(If more than 3, attach info): <br /> 1. Name: C', fA-etz Title: f\'\AV <br /> 2. Name: Title: <br /> 3. Name: i Title: <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 health care professional's facility. <br /> Applicant Signature: A , Date: <br /> Title: N)I Or UNA-e— <br /> - <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: ujs— Date: f0 i1/ 1-5 <br /> Expiration Date: j 2- l l Date Paid: 1,2 q 13 Cash or Check Received By: Zb <br /> EHD 45-01 5/2/12 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />