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sA&OAQUN CO GIC HEALAkERVICES D <br /> ENVIRONME14TAL HEALni DIVISION D,,. <br /> Medical Waste Management Program <br /> APPLICATION FORA LZM= QUANTITY HAIJUNG EXEMPTION <br /> To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Wasto <br /> Management Act", you are required to meet the following conditions: <br /> 1- Your medical office/business generates less than 20 pounds of regulated medical <br /> waste per week. <br /> 2- Your medical office/business transports less than 20 pounds of regulated medical <br /> waste at any one time. <br /> 3- Your medical office/business maintains records of any regulated medical waste <br /> transported offsite for treatment and disposal, including the quantity of the waste <br /> transported, the type of the waste transported, the date the waste was transported, <br /> the name of authorized person that trarisported the waste and the destination of the <br /> waste. <br /> PLEASE COMPLE c THE M—FORIMATION BELOW AND MAM WrI?? ' _l� ON FEE <br /> TO: <br /> San Joaquin County Public Health Services <br /> RECEIVED <br /> Environmental Health Division AUG 16 10,594 l �� <br /> P.O. BOR 3W " SAN JOAQUIN COUNTY <br /> Stockton, CA 95201-0388 PUONME1ALSERVICES <br /> ENVIP,ONNTJTALHESERVICES <br /> 01'JIS10N ®" � <br /> Medical Waste Hauler Information <br /> 1 Medical 0111ceMusiness Name: <br /> Medical ce loess Address: 4 i <br /> C'Vy State: Zip Code: <br /> Contact Person: Phone : <br /> Permitted Treatment Facility Name: etrni< : <br /> Permitte Treat ent Facil Address: <br /> C' ,a..,�®, ice State• Zip Code: <br /> Please list employee names and titles authorized to transport the medical waste. <br /> 1- Name- Tide: <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: ' Permit #: <br /> Storage Facility <br /> /address: C <br /> City: ,�. '�, State:CZ44Z Tap Code- <br /> A copy of this exemption and a tracking document containing the information above shall be in <br /> employees possession at aq times white transporting medical waste. In addition, all copies of <br /> medical waste records shall be kept on file it your facility. <br /> Applicant Signature• yt Title• C r�CL– Date: <br /> R.E.H.S. Application Approval: Date: q <br /> EH 4S 02 12-2-91 <br />