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C . 1% t <br /> •u l N PAYMENT • <br /> �o.PQ .coG RECED• <br /> IVESAN JOAQUIN COUNTYRECEIVr , _ <br /> ' <br /> N { 13 2011 ENVIRONMENTAL HEALTH DEPARTMENT 2— <br /> DEC w: <br /> NME oUN <br /> 1oAai`/ 600 East Main Street, Stockton, CA 95202-3029 0 <br /> 11 <br /> ENVIAO 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehdDEPAR <br /> �EI, <br /> a�IF:Oft <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEN 0T <br /> ,"_ � e lF <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: FILE <br /> C <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 Informatlon <br /> New �(Renewal <br /> Medical Office/Business Name: AIS weAVness _ <br /> Medical Office/Business Address OLAoo baset��kio Qr �► 1dC� <br /> (ref ff aA vw1r1 <br /> Cit State Zip Code <br /> Contact Person: 6-re v) <br /> Phone Number: Lfk, co <br /> Storage Facility Name: S vUlGPS3 <br /> Storage Facility Address: 7 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: T"�)CS (l S2'ft/�1 t� <br /> Permitted Treatment.Facility Address: M L <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. Z_ Title: VIIIA. <br /> 2. Name: i Llk Title: <br /> 3. Name: _7CkY`1ve s (`fly k Ned- Title: T <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: Date: a[ <br /> Title: "6o���1?� <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: jd „ Date: t70//Y/// <br /> Expiration Date: 1Z'/3 1 112- Date Paid: 12-/ 13/ 11 Cash or heck# 17128 Received By: 06/ <br /> EHD 45-01 11/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION <br />