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SAN JOAQUIN COUNTY <br /> PD ONMENTAL HEALTH DEPAR TT REC WENT� 6v0 East Main Street, Stockton, CA 95202-30L> eivEQ <br /> t" O <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd DEC 2 <br /> 8 2009 <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPT81% AQUIN COUNTY <br /> MEN <br /> HEALTH pEpgRTTA N <br /> To qualify for a"Limited Quantity Hauling Exemption"pursuant to the "Medical Waste Management Act",the folaing <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: <br /> San Joaquin County Environmental Health Department <br /> Medical Waste Management Program <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Medical Waste Hauler Information <br /> ❑New ®'Renewal <br /> Medical Office/Business Name: 6 IA <br /> Medical Office/Business Address: _4.2 0 5' "jV" S.`. <br /> 11.E d� •� c-q G �3 <br /> City State Zip Code <br /> Contact Person: C4W_�, �;� ";Iv:l CN4/C06? <br /> Phone Number: 'y 0 1 - 43 G <br /> Storage Facility Name: bve-ZQA-6 del: ,,`.141 2¢" <br /> Storage Facility Address: 4a0.s` e . A)"W'VIC -51. <br /> 148,0,,`A ef-4 S3 <br /> City State Zip Code <br /> Permitted Treatment Facility Name: .,2;�h <br /> Permitted Treatment Facility Address: 4/1 3,55 <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�I,�X �,. �, J fz Title: <br /> 2. Name: r•e_r s Title: Am <br /> 3. Name: 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 medical waste records shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: Date: ��-j�•- <br /> 61 <br /> Title: �i. �rr�G�,, ',,,;s s <br /> DO NOT WRITE BELOW THIS LINE <br /> R.E.H.S. Application Approval: r3 tii:� C` �;:;v..— f Date: �/��\?- / <br /> Expiration Date: I / 3 j /(7 f�Date Paid: � /2heck9 / 001 Cash o C # 623�,3 Received By: �✓ <br /> EHD 45-01 <br />