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l <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehdMAR 2011 <br /> JOss.Q'UIv <br /> EWRON , OWRjyY <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION T DEPARTMr , <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,transport 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 <br /> or a 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 <br /> to 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 ® L,,-)O (D k`Lb (o <br /> Medical Waste Management Program 6.0 9,6 q 519 <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> ob3'l2K <br /> Medical Waste Hauler Information � R `1 <br /> New ❑ Renewal f k O S 3 `Z <br /> Medical Office/Business Name: Pr( <m A- -- f40cP L C4E <br /> C 4- <br /> Medical Office/Business Address: ll®f Sy t-uo to 140e. STS <br /> Cn 0 U E S rc CA 9S73.S-AD <br /> City State Zip Code <br /> Contact Person: e 4t2", "bt014 t, <br /> Phone Number: - 333- 3lo <br /> Storage Facility Name: 0 P n M641. H l C--' CA 2 <br /> Storage Facility Address: l(®t 5K4,W jq M A(l . ST r — J a <br /> TGY1 o A S W CA: 9 S3 S0 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: fM�_P-jCVCL4E <br /> Permitted Treatment Facility Address: q((3 0 W. Stns t F- r A-U(E <br /> s 610 Cp l37a2^ <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the medical waste(If more than 3, attach info):1.Name: U 1C-K g I.0�C- Title: 121 C'45e '�'1ti(3 !UA e&� <br /> 2.Name: Title: RN rna.A) Ck <br /> 3.Name: hgFL31B( is t t C E Title: 6211/ rASE A1 )"C t? <br /> r <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. �n <br /> addition,all copies of medical waste records shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: ��� � Date: <br /> Title: at=c r-Dr2 D g 9 A--r l 1`NT -,:asP-U(CFS <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: <br /> Expiration Date:�/31 / 1 Date Paid: / / \ ` (mak-m-Check lo Q Lk, Received By: <br /> EHD 45-01 ' ,n,'4 ,1 4 7(l Jam, <br /> 11/19/08 (/t W r <br />