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DEC 2 7 Zola <br /> SAN JOAQUIN COUNTYT TIA <br /> WARONMM <br /> r ENVIRONMENTAL HEALTH DEPARTMENT <br /> u, 600 East Main Street,Stockton,CA 95202-3029 P T' <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sigov.org/ehd <br /> 1. <br /> APPLICATION 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$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 /> p New (1 IGnewal <br /> 7 <br /> Medical Office/Business Name: - <br /> Medical Office/Business Address: s <br /> City Staty Zip Code <br /> Contact Person: OAA,�*w <br /> Phone Number: i;,0/-134-�F-qti i <br /> Storage Facility Name: �� die ffosn � e �ili,�s �s <br /> Storage Facility Address: <br /> City State Zip Code <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: yt jS Si,:E f A-ti- <br /> Fit�z vv G'R :fj7.7 <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: A7.avx 'Seka,lLz Title: ;'n•.��ti �oy.caa«tf/fi/ �c�ui�s <br /> 2.Name: a-a: •.v Title: AM/- /1o.ts e kap e-4 <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 /> n I Date: / z-/J <br /> Applicant Signature: &�✓ <br /> Title: j�a�z�ah <br /> _ DO-NOT WRITE BELOW THIS LINE <br /> R.E.H.S.Application Approval: Date: <br /> Expiration Date:_L,1�/I/ IL Date Paid: 1 t C Check#: Received By: <br /> EHD 45.01 <br />