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SAN JOAQUIN COUNTY <br /> ENTAL HEALTH DEPAR C�IV�G <br /> ENVIRONMENTAL <br /> ., 304 East Weber Avenue, 3rd Floor, Stockton, CAW92 �C <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd S,qN �0Q� <br /> LIfioR� ���'q�UlCd C'•�r <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTI f r"1DEW,.i.lwrf, 1 <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 $70.00 fee to: <br /> San Joaquin County Environmental Heaitil Department <br /> Medical Waste Management Program <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> Medical Waste Haller Information <br /> ❑ New Renewal HouseCalls <br /> Home Health Agency <br /> Medical OfficeBusiness Name: 1250 S. Wilson Way, Ste. B2 <br /> Medical Office/Business Address:. Stockton, CA 95205 <br /> Cit �� State Zip Code <br /> Contact Person: LKA\5. <br /> Phone Number: s <br /> Storage Facility- Name: P�- n <br /> Storage Facility Address: I x•W t sr-,ta uj - 6 <br /> +04, <br /> City State Zip Code <br /> Permitted Treatment Facility Name: . ' <br /> Permitted Treatment Facility Address: qji St- <br /> (� <br /> City State Zip Code <br /> List all employee names andtitlesauthorized to transport the medical waste(If more than 3,attach info): <br /> 1. Name: ��u,`I \s {`�1� - Title: OW, N V, — <br /> 2. Name: Zo L,6 1 V-, v>1 beer _ Title: Li - <br /> 3. Name: Title: <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times white transporting medical waste. In <br /> addition,all copies of medical ste rec , ds steal a pt on file t generator's or health care professional's facility. <br /> Applicant Signature: Date:1o0C _ <br /> Title: Cao <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: <br /> Expiration <br /> Expiration Date: Date Paid: rot l lt9Z Ca or <br /> 9ck 1�j� �_ Received By: <br /> E}43 45-02-001 <br /> 101712003 <br />