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PAYMENT <br /> SAN JOAQUIN COUNTY <br /> y { ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue, 3"d Floor, Stockton, CA 95202-2708 14 zoo6 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> SAN JO/,QtJrrd COUNTY <br /> �a rUvirialq&41:NFAL_ <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIO" Al--"DEPARTMENT <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$72.00 fee to: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 304 East Weber Avenue,3"d Floor, Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> ❑New 'ARenewal HotlseCalls I-lame Health.Agency <br /> Medical Office/Business Name: 1050 N. Union St, <br /> Medical Office/Business Address: ^ Stockton, CA 95205 <br /> �y <br /> city State Zip Code <br /> Contact Person: C tK`A-is vtr. <br /> Phone Number: o'ZQ!�iIP 3 — E"�� <br /> Storage Facility Name: e:-LIIS e, <br /> Storage Facility Address: )© "N Sok` . <br /> City State Zip Code <br /> .Permitted Treatment Facility Name: Il�j,�Cs�G �(�• __ <br /> Permitted Treatment Facility Address: 3S <br /> Yves VW C 41N �AmaAp- <br /> City State Zip Code <br /> List all employee nameA and titles authorized to transport the medical waste(If more than 3, attach info): <br /> 1. Name: btxl5 &oZVti Title: <br /> 2.Name: a yStvW00at Title: C t %te— c- <br /> 3. Name: " % Title: WN <br /> A copy of this exemption andq tracking document shal be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medica aste re or all on file at nerator's or health care professional's facility, <br /> Applicant Signature: Date: -LjC.�2 <br /> Title: <br /> DO N T WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval- Date: f�lZ3l� <br /> Date: /L/Date aid: 2— <br /> Expiration Sash-ar-Check#: ?S'9 S 2 Received By; N C� <br /> EMD 4s-01 <br /> 07/31/06 <br />