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SAN JOAQUIN COUNTY MAY 1 9 2009 <br /> ENVIRONMENTAL HEALTH DEPARTMENT ENVIRONMENT HEALTH <br /> . 4' 1 600 East Main Street,Stockton, CA 95202-3029 TSSRVICES <br /> \ P• Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> 9�lFpRa <br /> 0py <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 /> NT <br /> Please complete the information below and mail with $77.00 fee to: EE <br /> RECEICEIVE. <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program MAY 19 2C4;. <br /> 600 East Main Street, Stockton,CA 95202-3029 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> Medical Waste Hauler Information HEALTH DEPARTMENT <br /> few ❑Renewal <br /> Medical Office/Business Name: �t wdlolss <br /> Medical Office/Business Address: � D{" A11 ` C <br /> City State Zip Code <br /> Contact Person: ILL Svc <br /> Phone Number: a <br /> Storage Facility Name: —P�p&L•7 i EH kCLp — l j� Sin jQ"::�,j kn C1 f-y <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: S COUPLUI(vC - <br /> Permitted Treatment Facility Address: I 61 <br /> City State Zip Code <br /> List all employee namAes and titles authorized to transport the medical waste(If more than 3, attach info): <br /> A t <br /> 1.Name: (-�n(,.l w,?-�- Title:2. Name: Title: <br /> 3. Name: 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 <br /> addition,all copies of medical waste records s all be kept on file at generator's or health care professional's facility. <br /> ,! / Q <br /> Applicant Signature: �- V1 J Date: '15I g& I <br /> Title: { <br /> DO ;- 4 <br /> 5RITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: /b/w- <br /> Expiration Date: f Z l ✓tel l Q9' Date aid: / I C� C� Ees" heck# 2 (o(o Received By: s' <br /> EHD 45-01 <br /> 11/19/08 <br />