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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> y'. < <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> e4.•..;' ° (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.orglehd <br /> �rFOrt <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 ����o v <br /> Medical Waste Management Program <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 I (� /oZ <br /> kfy <br /> Medleal Waste Hauler Informatlon <br /> ❑ New Renewal <br /> Medical Office/Business Name: &o(2alon <br /> Medical Office/Business Address 11721) `lei 1 fi� V2 <br /> Px'ca t Dln C'r� �i��z 0 <br /> Ry State. Zip Code <br /> Contact Person: �'he� <br /> Phone Number: 20ci- - 6SJ i D CKf <br /> Storage Facility Name: GL YI I? �C <br /> Storage Facility Address: C/� `15�0 <br /> city State <br /> State Zip Code <br /> Permitted Treatment Facility Name: 'Sin1 1 Ci <br /> Permitted Treatment Facility Address: QAkW 4-1'2Coy-no, is AV <br /> yerIlan C!A 9DID S <br /> City State Zip Code <br /> List all employee names and titles authorized to tra sport the medical waste(if more than 3, attach info): <br /> RA <br /> 1. Name: Hco, t(lf'X �, 00( 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 addition,all copies of <br /> medical waste records shall be kept on file at generator's or health care professional's facility. <br /> � "��' l01 �� <br /> Applicagt Si nat re: ` �k/\� toy` Date: �� 12-- <br /> Title: 1 Y1MA -S-e <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: Date: 1 <br /> Expiration Date: 11 1-3-Date Paid: /x--14 1 L2 Cash or Check#:t ) 8-1?03 Received By: <br /> EHD 45-01 512112 APPLICATION FORA LIMITED QUANTITY HAULING EXEMPTION <br />