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Q� SAN JOAQUIN COUNTY <br /> l� I EN,,-,AONMENTAL HEALTH DEPART,,14T E <br /> `. 600 East Main Street, Stockton, CA 95202-3029 1 <br /> P Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orglelz <br /> Cu <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, 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. <br /> Please complete the information below and mail with $77.00 fee to: PAYI\AENT <br /> San Joaquin County Environmental Health Department RECEIVED <br /> Medical Waste Management Program DEC 12 2008 <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> SAN JOAOtlI(V COUNTY <br /> Medical Waste Hauler InformationENVIRONMENTAL <br /> HEAL7F1 DEPARTMENT <br /> f-1 New Renewal <br /> Medical Office/Business Name: J h S ftUd�a Cal COO-f,-t- <br /> Medical Office/Business Address: N. � l.iati� S1Y'e <br /> A- R -8 <br /> City State Zip Code <br /> Contact Person: h <br /> K-�Iyld IP- <br /> Phone Number: - <br /> Storage Facility Name: h� ffi4j;Uj Cf <br /> Storage Facility Address: <br /> S q <br /> City State Zip Code <br /> Permitted Treatment Facility Name: S j• 5 U US Cffi ,-�Y- <br /> Permitted Treatment Facility Address: . S ee- <br /> 1 <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: Ike Quof"Alneeol- Title: <br /> 2. Name: Title: <br /> 3. Name: Title: <br /> A copy of this exemption and a tracking document s 11 be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medical waste records shall kept on file at generator's or health care professional's facility. <br /> Applicant Signature: =2 Date: 3 A g <br /> Title: f e df?gr, Iojs Suvra�Y� Ser✓,ccS <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: q Date: CZ/Del <br /> Expiration Date: --�Date Paid: Received By: 1� <br /> EHD 45-01 <br />