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Frroml 05/OB/2013 09:17 #560 P.00 02 <br /> = o <br /> SAN JOAQUIN COUNTY <br /> i ENVIRONMENTAL HEALTH DEPARTMENT <br /> •' 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> CiFipK <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify fora"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 $77.000 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program ,J <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Medical Waste Hauler Information <br /> ❑ New 12_�enewal <br /> Medical Office/Business Name: \AQa\�1 <br /> Medical Office/Business Address ! AL1(k00 !. <br /> 21a\C Ca t---) \9 <br /> City State Zip Code <br /> Contact Person: VO <br /> Phone Number: ?.0 C, <br /> Storage Facility.Name: <br /> Storage Facility Address: to f®o i+-� G wc, s 1 U a 1 <br /> City ''""__ ` State �iy� Zip Code <br /> Permitted Treatment Facility Name: 5trrvt CyGLt_ <br /> Permitted Treatment Facility Address: <br /> ,;vt �A�1cQvv Ccs QL4577 <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: iQroni yrl< go <br /> 2. Name: Gdoac 01 az R�j Title: <br /> 3. Name: tom s 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 bpt on file at=tralth care professional's facility. <br /> 7*1 <br /> Applica Signature: Date: <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: Date: <br /> Expiration Date: IT/'31 /1�lI.Date Paid: •Z / 7 / /3 Cash or Check#: ,56_65Z�Q Received By: LB <br /> EHD 45-01 512112 APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> Received Time May. 8. 2013 8: 24AM No, 0626 <br />