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>° oG SAN JOAQUIN COUNTY • <br /> y ENVIRONMENTAL HEALTH DEPARTMENT On <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> (j" <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> q� OR% <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 <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> IN New p Renewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: <br /> City State Zip Code <br /> Contact Person: <br /> Phone Number: <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: <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 /> 4� <br /> 1. Name: On n V1 Ct R_c.YC j% n R/J Title: <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 medical waste. In <br /> addition,all copies of medical wasteAreicords shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: Date: °i Lg IN <br /> Title: R a L <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: <br /> Expiration Date: / / Date Paid: / / Cashr Check#: 1( 2—l flReceived By: <br /> EHD 45-01 <br /> 11/19/08 <br />