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'oPQ'uilw ccs • SAN JOAQUIN COUNTY DEC 14 2011 <br /> . _ <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 0:. ` ENVIRONMENT HEALTH <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> •• s°°" ~� �• PERMIT/SERVICES <br /> (209) 468-3420 Fax: (209) 464-0138 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, 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 purcilant to Chanter 4 <br /> Please complete the information below and mail with $77.00 fee to: u a <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 Information <br /> ❑ New V Renewal <br /> Medical Office/Business Name: vZ4VIMS, <br /> Medical Office/Business Address t2lc2 AV5W1>� cS'u?9' <br /> S7DCI<7061 7 -A- 9so20-' <br /> Cil y State Zip Code <br /> Contact Person: D16 VA 0AOR69A <br /> Phone Number: R - F <br /> Storage Facility Name: EST/ cmLp Aa ASewlees <br /> Storage Facility Address: Moz peksW12174, Amoor YW <br /> City STV C/<-m , 1 Sate l Zip Code aO1 <br /> Permitted Treatment Facility Name: ' ©v ISL SV` / <br /> Permitted Treatment Facility Atldress' _ .(P02b__ <br /> -_gay -- <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: G11-DA DI. OA11, P ) Title: gEmik OF AUASIA)G <br /> 2. Name: A,,eaLVA) &7X0kk5M0, R Title: <br /> 3. Name: R/G! OUA N Title: &I, aA <br /> A copy of this exemption and atrack' 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 ke t file at generator's or health care professional's facility. <br /> Applicant Signat : Date: <br /> Title: t <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: Date: VL 16 A <br /> 'L � <br /> Expiration Date:�/�1/ 1L Date Paid: �/ (4 / Cash or em <br /> Received By: _ <br /> EHD 45-01 11/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION <br />