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Received: Sep 2 201 10:14am <br /> s 09/02/2011 10:01 2091151, PREFERRED ALLI PAGE 03/04 <br /> SA.N JOAQUIN COUNry <br /> ,... . <br /> ENVIRONMENTA1 HEALTH DLPARTMIENT <br /> � 600 East!vla;n Street, Stockton, CA 95202-3029 'ILC COPY <br /> a•__ �t Tefcphorre (209)468-3426 Fax:(209)468-3433 Pr'eh:www.sjgov.org/chd <br /> APPLICATION FOR A Ly—MYTED 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,transport Iess <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. Uiedical Wacfe Management Plan if the generator or parent organir_ation is a large quantity generator <br /> or a small quantity generator rcquim-d to register pursuant to Chapter 4. <br /> 2. Inrformat;on Document if the generator or parent organization is a small quantity generator not required <br /> to register pursuant to Chapter 4. <br /> Please complete the information below and mail with 577.00 fee to, <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 Info r. rotation <br /> ❑ New ❑ Renewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: <br /> Cr <br /> C State Zip Code <br /> Contact Person: <br /> Phone Number: <br /> d1o4 $- 136 ;L <br /> Storage Facility Name: <br /> Storage Facility Address: , <br /> � D <br /> city Statc Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: <br /> City State Zip Code <br /> List all employee names and titles authorized to transport the rI waste(If more than 3, attach info): <br /> T <br /> Ti -4 <br /> 1. Name- tle_ <br /> 2. Narne: Title-, <br /> 3.Name: Title: <br /> A copy of this exemption and a tracking document shall he in employees poeseRxion At ail times white trAroporting medical wan4c. in <br /> addition•all copies of medical wadtc records shalt be kept on file at gencraror'i or health care profemional'.f?tcHity- <br /> Applicant Si ature: 4� t� lS - Date,- <br /> Title: 1 <br /> DO NOT WRIT.F, BELOW THIS LINE <br /> R.E.H.S. Application Approval. Date: (o/ l%/ 11 <br /> Expiration Date: 12, /11--/A\—Date Paid.- (�/ �/ (� CRsh r Check tt C��7v Received$y; _ <br /> EHD 45-01 <br /> 11/I 9MR <br />