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�De.c._,.1.8.. =2012i210:�43RM,M San Joaquin County No 06654 P. 2 1. /1 a <br /> SAN JOAQUiN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT � <br /> 1866 East Hazelton Avenue, Stockton, CA 95206.6232 <br /> �x } (209)468-3420 Fax,, (208)464-0138 Web;www490v,or91ehd <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for a"Limited Quantity Hauling Exemption" pursuant to the"Medfoal Waste Management Acr,the following i <br /> conditions must be met: f <br /> , <br /> The generator or health care professional generates less than 20 pounds of mediaai 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. 'Medloal Wasto Management Plan If the generator or parent organization Is a large quantity geriomtor or a <br /> small quantity generator required to reglster pursuant to Chapter 4, , <br /> -•2:---informa1i6n Document.Itthd.g6gerator or•parent organization is a small quantity generator not required to <br /> register pursuant to Chapter 4. �- <br /> Please complete the Information below and mall with $71.00 tee to: i <br /> San Joaquin County Environmental Health Department <br /> Madloal Waste Management Program "PR <br /> 1868 East Hazelton Avenue, Stockton, CA 96205.6232 i 1 "Z <br /> Meolcal Waste Ffauler Informatl.o11 <br /> • r <br /> 0 Now Renewal i <br /> f <br /> Medleal OfficaMusiness Name; T.8WR1 Nr.E FAMIT,Y CENTER I <br /> Medical Offtce/Suslness Address 721 CALAVLUS 5T. _. <br /> LODI, CA 94240 <br /> City state Zip Code <br /> Contact Person: KATHLEEN MARSHALL ., <br /> Phone Number: (209) 373-2826 __ I <br /> 1 i <br /> Storage Faaitity N6tme; <br /> Storage raollityAddress: 2401 .W_ T•TmNER TiT} #450 LODI CA�,42 <br /> city State zip code <br /> - <br /> Penn itted=t'reafman'tFacility.NsMo_ STERICYCLE <br /> Permitted Treatment Facility Addross; 7 L"87_ IMI5E-R40GK..B -- �_ <br /> City state Zip Code <br /> Ust all employee names and titles authorized to transport the medical waste (if more than 3, attach Info): <br /> 1. NSMe, MARIA BARRON Title: ASSIT. CLINIC <br /> 2.Name: DIANA BARAYCQ Title: CLTNIC MANAGERE <br /> 3. Name: LII JACKSON_ --- Title <br /> A copy of this mxernpoon aitd A oeking document shaft bo to omployo9's possession at all times white transporting Medical waste. In addition,all copies or i <br /> medicaiwas to record$c.hall b pi n file a en ore 0rheatth care prorosaional's raclllty. <br /> i <br /> Applicant Signature: Date: --12118/32 <br /> Title: CE0 <br /> DO NOT WRITE 13ELOW THIIS LINE <br /> REHS Application Approval: Date, <br /> Expiratlon Dat®: \1-1 5k f_a Date Paid: 17l Casho Cher,[c .2J67`�5�—Recetved By;, <br /> APPt1GATION SORA LiMITeD QUANTITY HAULINt3 MXVMPTN <br /> IO <br /> t <br /> Received Time Dec. 18. 2012 10: 57AM No. 1896 <br />