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PpUly <br /> �o• �o� SAN .7OAQUIN COUNTY L "J R' <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> `.� 1868 East Hazelton Avenue, Stockton,CA 95205-6233 OCT 112013 <br /> Telephone:(309)468-3420 Fay:(309)468-3433 Y1 eb:«1?,zv.aj,ov.or,-`ehd <br /> :b, ENVIRONMENT HEALT <br /> APPLICATION FOR A LINUTED QUANTITY HAULING EXEMPTIMMIT/SERVICES <br /> To gttalifv for a"Limited Quantity Hauling Exemption'pursuant to the"Medical Waste Management.Act",the following <br /> conditions mast be met: <br /> The generator or health care professional generates less than 20 pounds of inedical waste per week, transport less <br /> than 20 pounds of medical waste at anyone 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. _-Vediccrl Waste.r'tfavcigencent Pima 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. If fornratioii Docrutleilt if the Generator or parent organization is a mall quantity Generator not required <br /> to register pursuant to Chapter 4. A D <br /> Please complete the information below and mail with$77.40 fe�lld4 p OV13-41-11, <br /> San Joaquin County Environmental Health Department 0 ti N <br /> Medical Waste Management Program ` � OV Z <br /> 1868 E. Hazelton.Avenue, Stockton, C A 95205-6333 q�ftvjw� <br /> H���D lyMLrMty <br /> Medical Waste Hauler Information E�"'� <br /> El New � Renewal <br /> 11'Iedical Office/Business Name: EGJI.l0Y1 Urvt� �e --�Y1G-}' <br /> Medical Office./Business Ad(h-ess: <br /> 9 Cal o'1 CA OFD32:D <br /> i1 <br /> City t��r !�cam'' State Zip Code <br /> Contact Person: t�t�c36M a t�yuo-p d 1 <br /> Phone Ntunber: sa — l-C) <br /> Storage Facility Name: nuc 04(e, <br /> Storage Facility Address: l <br /> &r: E ori C)q <br /> City State Zip Code <br /> Permitted Treatment Facility Name: f <br /> Pennittecl Treatment Facility Address: . <br /> e r <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical«paste(If more than 3, attach info): <br /> 1. Name: Ae(a+h c r-6" t[wad Title: <br /> 2. Name: Title: <br /> 3. Name: Title: <br /> A copy of this exemption said a tracking document sh.A be nu employee's possession at all dunes while trmusporting medical waste. hi <br /> addition,all copies of medical waste r ecords shall be kept on file at generator's or health care professional's facility. <br /> Applic tt Sig iattue: Date: �'12- 'J <br /> Title: > t C-�" I t 1�<�� e lAG <br /> DO NOT WRITE BnE`LO `S- THIS LINE <br /> R.E.H.S. Application Approval: Date: to /1L (3 <br /> ExpinationDate: L-z- S1 ..At Date Paid: ll ;` i'i'�3 Caslio•Chec : /00v�714,,,�ReceivedBy: <br /> EHD 45-01 <br /> 11/19/08 <br />