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P9-04-1998 G:3SPM-i FROM <br /> P. 2 <br /> Sa*oaquin County Public Heafth Servits <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXFJ.4PTION <br /> To qualify for a "Limited Quantity Hauling Exemption" pursuant to the"Medical Waste Management Act", the follo,.virg <br /> conditions must be met: <br /> The generator or health care professional generates less than 20 pounds of medical waste per week, transports less <br /> than 20 pcunds of medical waste at any one time, maintains a tracking document pursuant to Chapter 5, 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 or a small <br /> 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 to <br /> register pursuant to Chapter 4. <br /> PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH S67 FEE TO: <br /> San Joaquin County Public Health Services <br /> Environmental Health Division COD,Medical Waste Management Program A,,- <br /> 304 <br /> E Weber Ave <br /> Stockton, CA 95242 <br /> Medical Waste Hauler information <br /> New G Renewal <br /> Medi -nl Cff,=/Business Name: <br /> Medical Office./Business Address: <br /> City: C'-k- State. Zip Cade: 45-ao'DL- <br /> Contact Person: fit e 5n L�I V-11i Phone 2�r c,/�;,z—i�r41 <br /> Storage Facility Name: SS_ Cok, _ iwrUte:C4 A-,-,rn�1,i <br /> Storage Facility Address: 4O7 du- CA-t F -t— <br /> City: SState: Zip Code: <br /> Permitted Treatment Facility Name: �r a 5. <br /> Permitted Treatment Facility Address: t-H,�7h `t- <br /> City: -J State: Zip Code: <br /> List all employee names and titles authorized to transport time medical waste. If not enough space, attach information. <br /> t- Nane: PA4-_-e.. Ij k Title: Q-N 64ry"/V 1 S --;t <br /> 2- Name: 5t Title: CI >>v S ung c.r ort <br /> Nane: Title: 2ry ' <br /> 4. ivl. � f� <br /> A copy of this exemption and a tra*icing docarn shall be in anmployee's possession at alt times whale transporting medical wasts. in <br /> addition. aU copies of medical waste records shall be kept on fire at generator's or health ears profmsional's facifty. <br /> Applicant Signature_ <br /> Title- r,-Oy 641 MM Iry Date:d�j <br /> Do Not Write Below This line <br /> R-S.H.S. Application Approval: r Date: <br /> if--2 l C piratioR Date: !'sem / I <br /> EHs502 IC-03-96 Date Paid y / I / fY h or Check tol3 (circle) Acct y� , <br />