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oaquin County Public: Health Seri es <br />Environmental Health Division <br />edical Waste Management Program <br />APPLIC, <br />TiC N FOR A LIMITED QUANTITY HAULING DCEMPTION <br />To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Ac:', the following <br />conditions must be met: <br />The generator or health care professional generates less than 20 pounds of medical waste per week, transpors 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 an file one of the following: <br />1- Medica! Waste Management Plan <br />anithe generator <br />to Chapter organization <br />gan�tion is a large quantity generator or a small <br />quantity generator requiredregister <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 FcE TO: <br />San Joaquin County Public Health Services <br />Environmental Health Division <br />Medi -al Waste Management Program <br />304 E Weber Ave <br />Stockton, CA 95202 <br />Medical Waste Hauler Information <br />0 New G Renewal ' <br />1A r1V <br />Medical Office/Business Name. Home Health. and Hos ice of <br />Medical Office/Business Address: N. Trac Blvd. <br />State: <br />racy CA_ Zp Code: A 5 � 2L— <br />City: <br />� <br />City: Phone 8209-833-2463 <br />Contact Person: Ka M <br />Storage Facility Name: Sutter Trac Communit H <br />Storage Facility Address: utter Trac Communit <br />State: Zip Code: <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 />�- Name: See Attached List <br />2- Name: <br />3- Name: <br />Title: <br />Title: <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. <br />addition. all copies of medical waste records shad be kept on file at generator's or health care professionars fatality. <br />Applicant Signature:_,_, <br />Title: Home Heal <br />Oo Not Write Below This Line <br />2. E.H.S. Application Approval: <br />Date Paid i 1 l / 1i D l <br />EH4502 io-03-96 <br />ate:--- / <br />Date• / ZIaExpiration Date:/Z-/ �l / <br />Cash or Check T_ (circle) Acct <br />In <br />