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20311467159 0 °4:14 a.m. 05-24-2012 2/4 <br /> o.�au�7 o SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> • 600 East Main Street, Stockton, CA 95202-3029 <br /> e: •cava• • :e <br /> Ctq`-OR:•`• <br /> (209)468-3420 Fax:(209)464-0138 Web:www.sigov.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 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: PAYMENT <br /> RErFIVE.0 <br /> San Joaquin County Environmental Health Department MAY 2 4 2012 <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 &M,toAQuet MUM <br /> EWRONNENTAL <br /> Medical Waste Hauler Information JMALTH° ENr <br /> 0 New IIIYRenewal <br /> Medical Office/Business Name: .SC4 <br /> 4 <br /> Medical Office/Business Address yS <br /> Cltb � ��State Zip Code <br /> Contact Person: <br /> Phone Number. .20 — oa <br /> Storage Facility Name: ,XPi mg= 0.6 —_ <br /> Storage Facility Address: <br /> City State Zip Cads <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: ; <br /> city State 2jp Code <br /> List all employee names and titles authorized to transport the medical waste(If more than 3,attach info): �.e&&Ca4tQ <br /> 1. Name: Title: <br /> 2. Name: Title: <br /> 3. Name: TiOe: <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 an file <br /> at generators or health cera rofessionars facility. <br /> Applicant Signature: _6 Dater <br /> Tittle: ` <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: s Date: tAl k- <br /> Expiration Datta: fly /Date Paid: / 1 ash r Check#: Received By: <br /> EHD 45-0111129111 G APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION <br />