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LF <br /> SAN JOAQUIN COUNTY RVL <br /> ECENNT <br /> < r - ENVIRONMENTAL HEALTH DEPARTMENT / �r ED <br /> N' 1868 East Hazelton Avenue, Stockton, CA 95205-6232 �+CC 6 2819 <br /> jFOR ` (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehdAQij��a/ <br /> HE4LTh 0 1*I ,4j <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: i D r 2 <br /> San Joaquin County Environmental Health Department APPROVED t <br /> Medical Waste Management Program ; / . 1 2� <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> t <br /> Medical Waste Hauler Information <br /> ❑ New Renewal <br /> Medical Office/Business Name: SGS ')oa,�0-k-n an, ryy"A 0-�(-Q- t,� G-AUcrtb-cn <br /> Medical Office/Business Address 7;10'1 J,(iU Ssy�-,()c1 Dr <br /> to(ktx) (A - "�0 <br /> City State Zip Code <br /> Contact Person: Cur2nrelti2ni, ,,P, Pck1:U3 Prc,rnS <br /> Phone Number: Zf61 - 'AU 1� - U(1--1 LVO <br /> Storage Facility Name: SCY'1 ,)CqC (; <br /> Storage Facility Address: '1c-jCYC' <br /> City &'-U(JK-rtYl State (A Zip Code CiT.C>U <br /> Permitted Treatment Facility Name: S`DLr- S �,ran\AG�.nCZ, <br /> Permitted Treatment Facility Address: C <br /> �--)A I),0 1 —CSL `1-1 <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: S'1e i%� C o---A.�0 Title: 10 r. n P m o nns <br /> 2. Name: he r� Title: CAcrck*%y!�-:�-off S(-hbo`� _r, , ,, <br /> 3. Name: Ccne, l;cs1 �5��� Title: CCo(A',wnJL,< --r-Z c,ckic 1 n\-A 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 ke nfile a enera rs or health care professional's facility. <br /> Applicant Signature: Date: 12'3 -k3 <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: Date: <br /> Expiration Date:L/ / Date Paid: /z/j • / /� Cash o ��1D Received By:_ <br /> EHD 45-015/2/12 ^ Z— APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />