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*Joaquin County Public Health Sees <br />Environmental Health Division <br />Medical Waste Management Program <br />APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />To quality 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 />;han 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 fallowing: <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 INFORMA110N BELOW AND MAIL WITH Scc"7 FEB 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 />❑ New G Renewal <br />Medical Office/Business Name: Home Health and Hospice of Sutter Tracy <br />Medical Office/Business Address: 1420 N Tracy Blvd <br />City: Tracy State: CA Zip Code: 95376 <br />Contact Person: Laureen Ross RN Phone #-209-833-246 <br />Storage Facility Name: Sutter Tracy Community Hospital __ <br />Storage Facility Address: 1420 N Tracy Blvd <br />City: Tracy State: CA Zip Code: 95376 <br />Permitted Treatment Facility Name: S/A <br />Permitted Treatment Facility Address: <br />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 />1- Name: *See attached list Title: <br />2- Name: Title: <br />3- Name:_ Title: <br />A copy of this exemption a d a tracking document shall be in employee's possession at all times while transporting medical waste. In <br />addition, all copies of medll waste records shall�pe�kept on file at generators or health care professicnars facility. <br />Applicant Sign <br />Title: C V, <br />Q.E.H.S. Application Approval <br />EH4502 10-03-96 Date <br />Do Not Write Below This Line <br />Date: 2.// /OZExpiration Date: 1213//02'' <br />Cash or Check s 1013511 (circle) Acct_ <br />