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1-28-1998 3 : 19PMrlhl P. 2 <br />*� S n Joaquin County Public Health Services <br />Environmental Health Division <br />Medical Waste Management Program <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, 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 <br />register pursuant to Chapter 4. <br />PLEASE COMPLETE THE INFORMATION 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 Q Renewal <br />generatgX not required to <br />t - <br />r15 <br />n <br />Medical Office/Business Name: Home Health & Hospice of Sutter Tracv Com=ity Hospital <br />Medical OfficelBusiness Address: <br />1420 N. Tracy Boulevard <br />- <br />City: <br />Tracy State: CA <br />Zip Code: <br />Contact Person: Kris Nelson, <br />RN <br />Phone #: 209- - <br />Storage Facility Name: S„i-t-Pr <br />Tracv community Hospital <br />Storage Facility Andress: <br />- <br />City: <br />State: <br />Zip Code: — <br />Permitted Treatment Facility Name: <br />Sutter Tracy Community Hos! pi <br />Permitted Treatment Facility Address: <br />s a <br />City: <br />State: <br />Zip Code: <br />List all employee names and titles authorized to transport the medical waste. If not enough space, attach information <br />1- Name: see attached list Title: <br />2- Name: Title: <br />3- Name: Title: <br />A copy of this exemption and a tracking document shall be In employee's possession at ail times while transporting medical waste. in <br />addition, all copies Of medical waste records shall W kept on file at generator's or health can professional's facility. <br />Applicant Signature: G�t f u -C' ,t✓ry <br />Title: Home Health Manager Date:/ / 9 <br />Do Not Write Below This Line <br />R.E.H.S. Application Approva . �iT ate• �/ ?j/ I <br />-c2�'�expiratiaa Date: <br />EH4502 14-03-46 Date Paid�% ! � ! Cl� Cash ori ec # 41'532.& (circle) Acct <br />