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_o°'Q•u�N'••e SAN JOAQUIN COUNTY 10 eD <br /> Q, ENVIRONMENTAL HEALTH DEPARTMENT <br /> DEC 2 2011 <br /> •2 <br /> '+ '{ 600 East Main Street, Stockton, CA 95202-3029 <br /> •' reeon, <br /> (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgovENVIR.org/ehd dNMENTHEALTH <br /> o'R`'�P PERMIT/SEHVICES <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: M <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> El New Renewal <br /> Medical Office/Business Na e: sedo i C.Q_S !-0LAy1&a-k1 un <br /> Medical Office/Business Address 41 bo Du lo(I 11 Vd :-l�tl✓no <br /> �t�:2 l In G4 r 9 4&& <br /> City State Zip Code <br /> Contact Person: <br /> Phone Number: 12.G - I?,L,Z <br /> Storage Facility Name: 4c,-&,14•-k 1,- rk i CL,6 Fbundry►on <br /> Storage Facility Address: S I+Afla y-1 RaWdC, 2 <br /> City State <br /> Permitted Treatment Facility Name: ,1 Y1 <br /> Permitted Tre;3tmPnt Facility Address: ____1 s 4, <br /> esrto Z <br /> City State Zip Code <br /> List all employee names and titles�Ny�,Llthorized to transport the medical waste (If more than 3, attach info). <br /> 1. Name: !O klve 6\1 Title: D <br /> 2. Name: P-am ret. Title: 7�ri,re.f /I'Yled,r f•c <br /> 3. Name: 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 be kept on file at generator's or health care professional's facility. <br /> Applican Si nature: l GYM Date: <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> REHS Application Approval: Zj� IL. Date: 01/ C&/�2- <br /> Expiration Date: Q, /�) / Date Paid: (2, Cash or Check#: Received By: <br /> EHD 45-01 11/29/11 APPLICATION FOR A IMITED QUANTITY HAULING EXEMPTION <br />