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San 6—quin'County Public Health Serviclq <br /> nvironmental 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 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 ` , t 1 `� /t'e <br /> Environmental Health Division �j ` C) 6 <br /> 2 <br /> Medical Waste Management Program �) ` ��� �`� �1 D <br /> j <br /> 304 E Weber Ave <br /> Stockton, CA 95202 J <br /> Medical Waste Hauler Information <br /> ❑ New/R1 Renewal <br /> Medical Office/Business Name: - <br /> Medical Office/Business Address: 5--7p(7C1 C o nQdQ-\ tl y� <br /> City: State: Cjc� Zip Code: <br /> Contact Person: Phone #: <br /> Storage Facility Name: C(�'�"� <br /> Storage Facility Address: <br /> City: State: Zip Code: <br /> Permitted Treatment Facility Name: aYrip_/ <br /> Permitted Treatment Facility Address: <br /> City: State: Zip Code: <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> 1- Name: 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 all times while transporting medical waste. In <br /> addition, all copies of medical waste records shall bekept on file at generator's or health care professional's facility. <br /> Applicant Signatura )ILj:j,=, <br /> Title: ( IpF/bif- LIQ ria vx ez- 0Dater g Fid <br /> Do Not Write Below This Line <br /> R.E.H.S. Application Approval: Date: / / Expiration Date: <br /> EH4502 10-03-96 Date Paid t?- / 10 /99 Cash or Check # I)f 76-1 (circle) Acct <br />