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`.o.t SAN JOAQUIN COUNTY PAYMENT <br /> ENRRONMENTAL HEALTH DEPARTIONT <br /> RECEIVED <br /> OPY 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd APR 4 2011 <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIOINIvIRO nENTALNTv <br /> HEALTH DEPARTMENT <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. q <br /> Please complete the information below and mail with $77.00 fee to: Ov���( <br /> San Joaquin County Environmental Health Department a f-VV3733.5 <br /> Medical Waste Management Program k'0 53�Zo <br /> 600 East Main Street, Stockton, CA 95202-3029 A, Y5S�'7 <br /> Medical Waste Hauler Information <br /> j New ❑ Renewal <br /> Medical Office/Business Name: m�� �/s �/0;n el-171-k L <br /> Medical Office/Business Address: 20Z 00 GYy v6X2 <br /> / 0 G <br /> City State Zip Code <br /> Contact Person: Gvn T <br /> Phone Number: r a <br /> Storage Facility Name: n&ai5 GAZ. <br /> Storage Facility Address: Mon <br /> -jo 1.�n, I -# - -- T-W--,� <br /> City ) State Zip Code <br /> Permitted Treatment Facility Name: 0 U ( C � <br /> Permitted Treatment Facility Address: .QGt <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 /> �°A <br /> 1. Name: A. Aa1I Title: / <br /> 2. Name: 1 Dd' Title: AI <br /> 3. Name: Title: <br /> A copy of this exemption and a tracking docu nt shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical waste recor shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: YI ShZ`V)< 16q Date: <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: -4-/-&-/ 11 <br /> Expiration Date: /�_/ Date Paid: 14 /1( Cash Check : 55 0 43 Received By: <br /> EHD 45-01 <br /> i 1/19/OR I IM1 �I S 3�S <br />