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JAN-20-2010 12:35 FROM:LINDEN UN FIED M&O 9460457 T 4683433 P:1/1 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT M <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3470 Fax. (209)468-3433 lVeh:www.sjgov.org/6hd Z-k�Z LJ <br /> 12010 <br /> 84N IA4 ') <br /> 1�2010 <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EkEMP V/Ro/vm1EIV 01JNIY <br /> 711. <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the"Medical Waste Managemcnt <br /> g <br /> conditions must be met: T <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 Chaptcr.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 purstmrl to Chapter 4. <br /> 2. fqfoi7nation D6clondne if goerafpf-or p0dbf organization is a small quantity generator not required <br /> to register pursuant to Chapter 4. <br /> Please complete the information below and miil with 577.00 fee to: <br /> San Joaquin County Environmental Health Department F�k <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 --Tb* <br /> Medical Waste Hauler lnformation_(��(au_� <br /> El New W Rmewal <br /> Medical OfflceMusiness Name: InAeir'� <br /> Madicaa Office/Business Address: Wki g <br /> ON State Zip Code <br /> Contact PCs= <br /> Phone Number- 50 )(n0c) <br /> Storage Facility Name: U!p d ton <br /> Stoi,agc Facility Address: INGO ja EIC221 <br /> City StatcCoda <br /> Perwifted Treatment Facility Name: �-nevoz - <br /> Pen-nitted Treatment Facility Address: clew - H&M.- 1-0or <br /> 11(000 W, -helub <br /> 40T_4 <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste (If more than 3,attach i o): <br /> 1.Name: lbal- Title- ffia-&:50 <br /> 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 rdedlcal waste. In <br /> a d(iltion,all copleq of medical waste records s be kgptep fele t generator's or health can professional's facility. <br /> I e a <br /> Applicant Sipature: Date: -2'0"tp <br /> Tit1c: <br /> DO NOT WRITE BELOW THIS LINE <br /> RX.H.S. Application Approval: Date: tL24!10 <br /> Sxpjratjoi)1D;1tc: 17-1 Sl / /0-Date Paid: Cash or Check#:"S 15�3%ceivedBy: �11L <br /> EIM 45.01 <br />