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- <br /> y Ila <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 <br /> - - <br /> 1868EoetHazelton Avenue, Stockton, CAS5205-G232 - - �-"—^ <br /> (2O9)408-342OFax: C2O0A464-0138 ��: vm«mv 'go«oro/ohd /AN � � �Abi <br /> �y <br /> . APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIIc <br /> [oqualify for a"Limited CluanUtvHouUnQE�empUon"purauon�tn�he"K8ad�o|VVno�eK8onogennent�oC thafo||ovv <br /> cond��onamnusLb�nnot ' ' /»Q <br /> The generator orhealth care professional generates less than 2Opounds ufmedical waste per weah transports less <br /> than 2Opounds ofrnadica|vvoateatany one tirne. maintains mtracking docunnontpursuant hoChapter 8and the <br /> generator orparent organization has onfile one ofthe following: <br /> I. Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a <br /> small quantity generator required horegister pursuant hoChapter 4. <br /> ' 2. Information Document if the genenatororparent organization kaasmall quontitvgenerator not required tn <br /> -register pursuant voChapter 4. ^ <br /> Please complete the information below and mail with $77.00 fee to: U.8. He8lthVVo[kG. Inc. <br /> ' <br /> ' TaxDepartment <br /> EnvironmentalSan Joaquin County HealthDepartment 25124 riOgfie| <br /> Springfield Court, S <br /> uite2ODKodica|Vaabm8anogementp - C� B1���-1O"818O8EaatHaze|tonAvanue. S0o <br /> ckton, CA 95205-6232 <br /> a41111 1__�I <br /> Medical Waste H'-9--uler Information <br /> ONevv 13/Renewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address <br /> Contact Person: - ` ' "`ax, Zip ou <br /> t4 SO-el <br /> Phone Number: <br /> ' <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> city State Zip Code <br /> Permitted.Treatment Facility Name: MA <br /> Permitted Treatment Facility Address: <br /> City State Z_ Code <br /> List all employee names and enled�o| <br /> t�(if more than 3, attach info): <br /> 1 Nome' ''-- <br /> ' ' Title:2Nom� <br /> . Title: <br /> 3. Name: <br /> A copy of this exemption and <br /> moukm|v�x��cv��o�,o��kept on flIG at generatoes or health care professional's facility. <br /> ----~----'-^~~~ll^~~'"employee's wm/�ua»sP«mnomemca|wav�. maumun�aonvnmom <br /> Applicant_ Date: <br /> Title: ver _ <br /> DONOT WRITE BELOW THIS LINE <br /> REHG 11 <br /> Date: e�I/A�uA � <br /> ExpirmtionDoba DatePaid: Cash or Received By: <br /> Exm*5-u 5m12 <br />