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SAN JOAQUIN COUNTY <br /> EN*ONMENTAL HEALTH DEPART* <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> �c� P Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/eWtL L 8 2009 <br /> APPLICATION FOR A LIMITED QUANTITY HAULING ET HEALTH <br /> �RVICES <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: /�''�San Joaquin County Environmental Health Department (( }}IFT Medical Waste Management Program ��✓✓ �:•� <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> El New [Renewal <br /> Medical Office/Business Name: PAE-67/GC lktwe, dea/M cX�Yd%t'+l5 �C <br /> Medical Office/Business Address: o? Al. 9 - <br /> 1711- a <br /> �5�� <br /> City State Zip Code <br /> Contact Person: <br /> Phone Number: <br /> Storage Facility Name: 4we / 2 Tie <br /> Storage Facility Address: V. i nZ4f <br /> Citv State Zip Code <br /> Permitted Treatment Facility Name: W ,I&- . ; <br /> Permitted Treatment Facility Address: to p ���'--.c txt, cue., C Q, - <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: LzwTitle: /> 1 <br /> 2. Name: Title: <br /> 3. Name: �4/zall • I29V.� 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 shall be kept on file at generator's or health care professional'Vffacflity. <br /> Applicant Si ature: Date: <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: a7/4-4/ to <br /> Expiration Date: IL. /AL/1b-Date Paid: 0-- A\ Cash or eck#: AVI�j Received By: VM <br /> EHD 45-01 <br />