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a <br /> SAN JOAQUIN COUNTY <br /> { <br /> EN-. tONMENTAL HEALTH DEPARTIv„.g<T <br /> 600 East Main Street Stockton CA 95202-3029 FEC�I ED <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ���� <br /> D� <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTf [R0N N NTAL y <br /> VIRONMENTAt_ <br /> To qualify for "Limited HEALTH aEP,4 ryl t= <br /> q fy Quantity Hauling Exemption"pursuant to the "Medical Waste Management Act", the Wing <br /> conditions must be met: <br /> The generator or health care professional generates Iess 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: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> New <br /> Medical Waste Hauler Information <br /> ❑ Renewal HouseCalls Home Health Agency <br /> Medical Of eelBusiness Name: _ 1050 N. Union Street <br /> Medical Office/Business Address: _ Stockton, CA 95205 <br /> City Mate Zip Code <br /> Contact Person: <br /> Phone Number: <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> City l State Zip Code <br /> Permitted Treatment Facility Name: �1 <br /> Permitted Treatment Facility Address: <br /> City State Zip Code <br /> List all employee na es and titles authorized to transport the medical waste(If more than 3, attach info): <br /> 1. Name: S l'� Title: W ywy- _ <br /> 2. Name: rn Title: <br /> Title: <br /> 3. Name: ` <br /> 13 <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 medico ste re r s s kept on file at generator's or health care professional's facility. <br /> Applic ign t e: Date: <br /> Title: <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: _ Date: bVV 6/eN; <br /> Expiration Date: -/ / Date Paid: /� /O 3 / O� Cash o hec : /beep Received By: <br /> EHD 45-01 <br />