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08/15/2013 12:12 2094684955 COMP HEALTHRE Ef�b/02 <br /> i" SAN JOAQUIN COUNTY AUG 15 2013 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> '1868 East Hazelton Avenue, Stockton, CA 95205-6232 �RONMENTALHEALTH <br /> • ;: PERMIT/SERVICES <br /> ,fig (209) 468-3420 Fax: (209) 464-0138 Web:www.sjgov.org/ehd <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTI DN <br /> To qualify for a"Limited Quantity Hauling Exemption" pursuant to the"Medical Waste Management pct", the following <br /> conditions must be met: <br /> The generator or health care professional generates less than 20 pounds of medical waste: er week,transports less <br /> than 20 pounds of medical waste at any one time, maintains a tracking document pursuant Chapter 6 and the <br /> generator or parent organization has on file one of.the following: <br /> 1. •Medica!Waste Management Plan if the generatoror parent organization is a large luantity 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 ge erator not required to <br /> register pursuant to dhapter 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 /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Medical Waste Hauler Informat_lon <br /> C1 New 0 Renewal <br /> Medical Office/Business Name: SCrx7J�? U-AJn a- � iG�lAco-- ur <br /> Medical Office/Business Address <br /> 20- -cYaEt Ur�c1 n�tee.. <br /> city State Zip Code <br /> Contact Person: s �-° Cr) r n- i{2< i �r Q-h�.l �I v�- s --prvC��r� <br /> Phone Number: ��lp9 I'Itot) <br /> Storage Facility Name: "��7 <br /> l C a -i t� F Edyc�M <br /> Storage Facility Address: �U�OY\G\ 'l ,/1 v� <br /> City -�t7Y 1 State (A Zip Code �j2,(,`t o <br /> Permif ed Treatment,F2c. ility...Name:.... <br /> Permitted Treatment Facility Address: <br /> City <br /> State Zip Code <br /> List all employee names and titles authorized to transport the medical waste (If more than 3, attach Ifo): <br /> 1. Name: S'Y) � .? X'Y�� '�-N_ Title: Vk'f. GornpY�.l�ux_ <br /> 2, Name: 917hk o QVYt !ZI\I Title: rlogg slurs <br /> 3. Name. �e X5 5�1��1 Title: --- <br /> A copy of this exemption and a tracking document shall be in®mployee's possession at ail times while transporting medici waste. In addition,all coplos of <br /> medical waste records shall be kep file at generato s or health care professlonars facility. <br /> Applicant Signature: Date: 11 O 12 <br /> Title: ID1Y r '1 Ir <br /> DoNOT <br /> ,, WRITE BELOW THIS LINE <br /> REHS Application Approval- Date: -- <br /> Expiration Date: %14 "111/ Date Paid. QL/#/ Q—Cash or eck Received Bv:1 <br /> EHS R e c e i v e d Time Aug. 15. 2 0 1 3 12:0 6 P M No. 3873 APPLICATION FOR A L11 1TE0 QUANTITY HAULING EXEMPTION <br />