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San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Prcgram <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To quality for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management A&,% 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 Ile 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 W17H S67 F"EE 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 /> Cl New Renewal <br /> medical Ofi"celBusiness Name:. K t CSN- �- 7 <br /> Medical OfiicelBusiness Address: a( 1-((U FA �� <br /> Stare. CZip Cade. .11 _ <br /> City: S I Phone , `i' <br /> Contact Person: i� i4 t NI A PiAL� ►.� <br /> Storage Facility Name: ak-/D,s ryl t _�- L E <br /> Storage Facility Address: _ State: CA Zip Code: of 5Q 0ta <br /> City: <br /> Permit Tr a S rJT (�lC mac` <br /> i.Led e_t*rient Facility Name:____®)_— <br /> Permitted Treatment Facility Address: �► State: Tp Cade: — <br /> City: <br /> List all employee names and titles authorized to transport the medical waste. if not enough space, attach information. <br /> Title:_ l "£f)1�CQI_ I'15�1 S7OY�-T <br /> 1- Name: 1�t Title: M — <br /> 2- Name: Title: 044 G, <br /> 3- Name: `2�c N 2ct3�t-Z <br /> A copy of this exemption and a tracking document shalt be in employee's possession at all times while otr;u porting medical waste. In <br /> addition, all copies of medical waste records shall be kept on file at generatars or health care prof <br /> nal's facirity. <br /> Applicant Signature-LA' � Date. I / I / 01 <br /> l <br /> Title: <br /> y `( - 1�1 Date: <br /> Do blot Write Below This Line <br /> : <br /> Date: / 9 / Z.I:xpiration Date: 12-13/102. <br /> ,Z.E.H.S. Application Approval <br /> VWA�n-7 ,n.n-;_a6 Date Paid <br /> 2 / / O Cash or Che <br /> s -511.11 (circle? Acct — <br />