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D <br /> o�qul c <br /> >:•.. .•.o SAN..IOAQUIN COUNTY � <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> JAN 2 <br /> •'=" 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Sfia <br /> c9�oRti�P (209)468-3420 Fax: (209)464-0138 Web:WWW.sjgov.org/ehd ENVIii0NMENT NUALT11 <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, 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. Infonnation Document if the generator or parent organization is a small quantity generator not required to <br /> register pursuant to Chapter 4. <br /> Please complete the information below and mail with$77.00 fee to: Receive, <br /> San Joaquin County Environmental Health Department APPROVE JAN 2 B Z��4 <br /> Medical Waste Management Program L e �,/oAQU <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 ELrH iE,�EN74L <br /> NEALrN Ep4R MEr <br /> Medical Waste Hauler Information <br /> ❑ New Renewal <br /> Medical Office/Business Name: ��,w1ecc <br /> Medical Office/Business Address Z2�1 VJe�� Er»��se bye <br /> -- <br /> City State Zip Code <br /> Contact Person: s c�oiiv�� �tCv� <br /> Phone Number: 7,Q o-PiMK <br /> Storage Facility Name: rr`Cc <br /> Storage Facility Address: VV-\rk CIA- <br /> City State Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: <br /> Cd_ <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: Title: D <br /> 2. Name: n V--Ku e-c zr' Title: Sch---,nl In vis <br /> 3. Name: -\i Title: <,c 3, c-o i Y1 t/✓S e <br /> A copy of this exemption and a tracking 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 kept on file at generator's or health care professional's facility. <br /> Applicant Signature: Date: 10 <br /> TitleAs k rz,_A t` G� 4eckw\--\ Sekkl i <br /> DO NOT WRITE BELOW THIS LINE <br /> RENS Application Approval: L �C .1_ Date: f /9/ <br /> Expiration Date:/ Date Paid: /2-9`//l Cash orChecl d#: 1&)-H&21 Received By: <br /> EHD 45-015012 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />