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SAN JOAQUIN COUNTY <br /> EI��ONMENTAL HEALTH DEPARTI�I <br /> y < U <br /> ,: _ _, _•, �i; a `� �-` � 600 East Main Street, Stockton, CA 95202-3029 <br /> :. Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sigov.orglehd <br /> PERWPLWAON 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$72.00 fee to: PAYMENT <br /> San Joaquin County Environmental Health Department RFC�P\/Fi) <br /> Medical Waste Management Program D -.-' 3 i 2007 <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> SAN JOAQUIN COUNTY <br /> Medical Waste Hauler Information ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> D New 1)1Renewal <br /> Medical Office/Business Name: 11050 Nalis Home Health Agency <br /> Union St. <br /> Medical Office/Business Address: Stockton, CA 95205 <br /> City , Zip Code <br /> Contact Person: ,IDA S G.SL` `X1 <br /> Phone Number: <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> City State C Zip C de <br /> Permitted Treatment Facility Name: _ _ _ S'r rt G e, <br /> Permitted Treatment Facility Address: qLg�5 �,V`L <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: L q$6—Tdr? Title: <br /> 2. Name: L, Title: ` <br /> 3. Name: J2 waLaU <br /> Title: <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In <br /> addition,all copies of medi aste a ds 11 kept an ti a at generator's or health care professional's facility.. <br /> Applican gna re: Date: 42-A(-07 <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: Date: -Al lgyl p� <br /> Expiration Date: 3J /O�Date aid: Ja l 31 /per CashCheck :I ffle Received By: <br /> ERD 45-01 <br /> 10/02/07 <br />