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SanuinpCounty-Public Health ServicQ& <br /> , <br /> Onvironmental Health Division d .� <br /> Medical Waste Management Program <br /> ( APPLICATION FOA A LIMITED QUANTITY HAULINGTI <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, transports 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 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 E INFORMATInN BELOW AND MAIL WITH $67 FEE TO: <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> 0 New Renewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: ig <br /> '' <br /> 1. 111 State: Zip Code: <br /> City: Phone <br /> Contact Person: <br /> Storage Facility Name: Sir <br /> Storage Facility Address: •State: Zip Cade: <br /> City: <br /> Permitted Treatment Facility Name: -� �•� <br /> Permitted Treatment Facility Address: State: Zip Code: <br /> City: <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> ® -f- Title: ! ✓ - • <br /> 1- Name:49� Title: <br /> 2- Name: 1 <br /> 3- Name: Title: <br /> le <br /> A copy of thisexemption <br /> of medical waste erste records hall be cking document ll be In ept on fie al generator's orlon at all times health care professional'slf transporting <br /> medical waste. In <br /> addition, all copies <br /> Applicant Signature: <br /> Title: 41iDate° <br /> Do Not Write Below This Line <br /> R.E.H.S. Application Approval: Date: ,Expiration Date: <br /> EHaSaz JG-03-96 Date Paid / �f/4,7'e7 Cash o eek `A�1 ''_S :zircle) Acct,14L�1- <br /> .V��•-+ <br />