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SAN JOAQUIN COUNTY <br /> !q' ' ENSONMENTAL HEALTH DEPART*T <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> FILE COPY <br /> P Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <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 $77.00 fee to: <br /> San Joaquin County Environmental Health Department DEC 2 1 ^i <br /> Medical Waste Management Program <br /> SAN JOgQUInd Aj O <br /> 600 East Main Street, Stockton, CA 95202-3029 H EEN�D� ANT <br /> Medical Waste Hauler Information <br /> ❑ New ❑ Renewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: 2=0q0 0 <br /> — 120946 <br /> City State Zip Code <br /> Contact Person: AN SSA \K I,LvklUcy),� <br /> Phone Number: b o Q14-119 <br /> Storage Facility Name: J�061 e, W I� 1N <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: Onoi)u/wOf <br /> Permitted Treatment Facility Address: Ix, <br /> j)ItE = <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:hfuD1-I Title: MM Atf,1Z <br /> 2. Name: Nolww mwr-a*3Title: Mh IL <br /> 3. Name: e Title: H <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 medica waste recor shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signatur . Date: 1 Z-I O-ZO <br /> Title: VI cc <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: i�<: y _ Date: i Z /'7>I/ V 41 <br /> Expiration Date: 1Z -31 Date Paid: 12- 1 / O 9 Cash or heck 9 3 Received By: Ll�> <br /> EHD 45-01 <br />