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�q San Joaquin'County Public Health Services <br />Environmental Health Di <br />Medical t _ *' • t <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 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 />O New iD Renewal <br />Medical Office/Business Name:_ <br />Medical Office/Business Address: <br />City: Tram - - - - - ®"""s <br />y+' " w - Stater Zip Code g r :1 <br />Contact Person: Kris Nal cnn , RK <br />Phone #: Zia•— r % <br />Storage Facility Name: S„t-t-ar Tracy Cnmm„n, <br />4 -.Kr ;Tn a 3 <br />Storage Facility Address: <br />Name: <br />City: <br />ate: Zip Code: <br />Permitted Treatment Facility Name: S„+ -ter, <br />ja i --> gas �a <br />Permitted Treatment Facility Address: ®®amg, <br />City: <br />State: Zip Code: <br />List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br />1- <br />Name: gee at-t-ari•hnA gist <br />Title: <br />2- <br />Name: <br />Title: <br />3- <br />Name: <br />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 caro professional's facility. <br />Appl <br />Title <br />Do Not Write Below This Line , <br />R.E.H.S. Application Approval- l,Q Date:, 3/ Expiration Date: 3/_._.-,- <br />EH4502 10-03-46 Date Iai / a-��� �j y :ash o eck # J ` 3 (circle) Acct <br />