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o�Q.urN c <br /> ,.• �. .oG SAN JOAQUIN COUNTY <br /> % FILE COPY <br /> e HEALTH DEPARTOINT <br /> . 600 East Main Street, Stockton, CA 95202-3029 <br /> (209)468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br /> 6Vz' <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 pursuant to Chapter 4. <br /> Please complete the information below and mail with $77.00 fee to: <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 Q(Renewal <br /> Medical Office/Business Name: e0kk�N �RXViCp, <br /> Medical Office/Business Address y.)eS•k (Louise /eve <br /> yy%0,,Y,ke c o, C-A 943 City State State Zip Code <br /> Contact Person: (ZX)"r "—e -0-1�boQU OI <br /> LA <br /> Phone Number: 2eq - SC ST- 0-mg <br /> Storage Facility Name: 1(�o.v�}ecn. V�Sp �.�,e�\�� S2V i[ S <br /> Storage Facility Address: Y1n.�...4ccA �► 9S S3'7 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: $ <br /> Permitted Treatment Facility Address: 4 L3S W . Swic-I- ¢rl <br /> r e_S)L--D Ci4 3-7 Z Z <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: C.o c-ok�h2 'M,,N0V(420.ti Title: V icy <br /> 2. Name: cc Title: ceryl Y�vcSe <br /> 3. Name: V 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 addition,all copies of <br /> medical waste records shall be kept on file at genera or's or health care professional's facility. <br /> Applicant Signature: d--- Date: <br /> Title: ti iccs-4-Oc- d 1-le a.l ms-v im n <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval:� -c�- Q - Date: ;- /L.6/Iii— <br /> Expiration Date: Imo/ 31112- Date Paid: 2- / I q/12-- Cash hec -7-271F13 C/ Received By: GSC. <br /> EHD 45-01 11/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION <br />