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1111 4 10:11:37 a.m, 02-06-2013 3/4 <br /> c <br /> P2 Iry "Ift <br /> SAN JOAQUIN COUNTY <br /> ={ <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton AVenue,Stockton, CA 95205-6232 <br /> (209)468-3420 Fax: (20g)464-0138 Web:www.sjgov.org/ehd <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 rile 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 wlih $77.7070 fee t�oc:T <br /> San Joaquin County Environmental Health Department "r.RO V"E - <br /> Medical Waste Management Program / <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Medical Waste Hauler Information <br /> ❑ New YRenewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address <br /> C, State Zip Code <br /> Contact Person: ._ _LX <br /> Phone Number. 209 — [nom D — g000 <br /> Storage Facility Name: ,,.,,Q, QS Dov <br /> Storage.Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: <br /> ` Perrriltted Trea ent Facility Address: - - <br /> 5 CL A-1 21 Ix <br /> - <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: Title: <br /> 2. Name: Title: <br /> 3. Name: Title: <br /> A copy of this exemp on an a d cument shall be in ompioyee's possession atall times while transporting medical waste. In addition,all copies or <br /> medical waste records shall be kept on eneratoYs or health caro protosslonars facility. <br /> Applicant Signature: Date: <br /> Title: <br /> DO NOT WRITEIBELOW THIS LINE <br /> RENS Application Approval: (' ,il_ - Date: Z <br /> Expiration Date: 1 Date Paid: 12 f a.7/l 2-- Cash or Check#: `f3?-c� Received BY: <br /> EHO 4501 512112 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> Received Time—Feb. 6. . 2013-10: 11AWA o: 2236--- ___�_.._..._...-. <br />