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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN�P 2�1�20 0`T9 kE <br /> C <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> P • Telephone:(209)468-3420 Fax:(209)468-3433 Web:ww5NW9( 4/ T HEALTH <br /> PERMIT/SERVICES <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 8Z3y � <br /> Medical Waste Management Program �CEO- <br /> $ <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information S3�g �tA <br /> �S <br /> New El Renewal t1� <br /> Medical Office/Business Name: LINDClU OAlr'i�fC(J 6/tin C_ 4 <br /> Medical Office/Business Address: 5 L,"7 } -`t" <br /> L SAW r,) r'11nj31-) <br /> City State Zip Code <br /> Contact Person: 1 r-i0'//4 19TE)AJ,S <br /> Phone Number: <br /> Storage Facility Name: <br /> Storage Facility Address: 1`6t13C1 L- . �t2n►� ST, <br /> 1 --►t,3%-) CQV1 on�3(� <br /> City State Zip Code <br /> Permitted Treatment Facility Name: C "�- S bP4 t <br /> Permitted Treatment Facility Address: hkoco K. kvS <br /> ilk-. V QZ9 <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-�TPFC yz-y—: q Title: k)cn,� , <br /> 2.Name: Title- <br /> 3. Name: Title: <br /> A copy of this exemption and a tracking document shall b emp yee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical waste records shall be k t o f e tor's or health care professional's facility. <br /> Applicant Signature: 7 Date: -1-7-001 <br /> Title: ^a <br /> DO N,10T WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: O /, Q/ag <br /> Expiration Date: Date Paid: / 91 /01 Cash or heck# 'f3'1'-L— Received By: <br /> EHD 45-01 <br /> 11/19/08 <br />