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LAW <br />SAN AQUIN COUNTY PUBLIC HEALTH VICES <br />IR HEALTH DIVISION <br />Medical Waste 9 1. Progrmr <br />APPLICATION FOR A LIMITED QUANTITY HAULING EIEMMON <br />To qualffy for a "Limited Quantity Hauling Exemption!' pursuant to the "Medical Waste <br />Management Act", you c • i • meet the following• • • • <br />Your • office/business generates less than 20 pounds of regulated medical <br />waste per week. <br />Your • •• transports - 1 pounds of -• -• medical <br />waste at any one time. <br />Your -• office/business maintains rec• • of any regulated medical <br />transported offsite for treatment an• disposal,including the quantity of <br />transported, - type of • - transported, the date the waste was transported, <br />the name of authorized person that transported the waste and the destination of the <br />PLEASE COMPLETE THE INFORMATION7 APPLICATION FEE <br />TO: <br />San Joaquin County Public Health ServicesYM T <br />Environmental Health Division A 7% : t4sejro ley RECEIVED <br />P.O. sox 2009 M AY 2 6 1992 <br />Stockton, CA 95201 SAN JOAQUIN VCUNry <br />pi i[31 it HEA13H 1;�7LtNICES <br />Medical Waste Hauler Information ENVIRONMIENTAL HEAL i r' Ulvi:,7 <br />Medical Office/Business Name: Tracy Community Memorial Hospital -Home Health Care Service <br />Medical Office/Business Address: 1420 N. Tracy Blvd. <br />City: Tracy State: CA Zip Code: 95376 <br />Contact Person: Elizabeth Kimball, RN Phone #:(2059) 835-1500 x4505 <br />Permitted Treatment Facility Name: --Tracy Community Memorial Hosp. Permit : 56387 <br />Permitted Treatment Facility Address: 14 0 N. Tracy Blvd. <br />City; Tracy e: CA Zip Code: 95376 <br />Please list employee names and titles r transport the medical waste. <br />1- Name; Please see attached list. fie• <br />2- Name: Title: <br />3- Name: Title: <br />If transporting medical waste to a permitted storage facility for consolidation purposes or if veterinarian <br />or home health care nurse transporting medical waste back to own facility, please complete the following: <br />Storage Facility Name: TRACY COMM. MEM. HOSPITAL Permit #: N/A <br />Storage Facility Address: D L . <br />City: TRACY State. CA Zip Code: 9 5 3 7 6 <br />A copy of this exemption and a tracking a inin the Information above shall be In <br />employees possession at all times while transportingmedical waste. In addition, all �opies of <br />medical waste records shall be kept on file r facility. <br />Home Health <br />Applicant Signature: Title: Coordinator Date: 05/20/92 <br />j <br />R.E.H.S. Application Appro : �" <br />EH 45 02 12-2-91 '► a <br />