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S %6quin County Public Health Servio <br /> an <br /> Environmental 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 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 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 COMPLEIE-1HE INFORMATION BELOW AND MAIL WITH 567 FEE TO: <br /> an Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> Mgdical Waste Hauler Information <br /> 0 New g Renewal <br /> Medical Office/Business Name: eh <br /> L -ke- <br /> Medical Office/Business Adores e: <br /> CityCA ip Cad <br /> : State. Phone : 6yg&f2 <br /> Contact Person: <br /> Storage Facility Name: <br /> Storage Facility Address:7E <br /> City: I <br /> 1,-if State: Zip Code: 96W4 <br /> Permitted Treatment Facility Name: <br /> jg I e. <br /> Permitted Treatment Facility Address: LjLj—LLAU1 <br /> City:_ .�a,--rawc State: Zip Code: <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> 10A W1/7 oeli-Ily,y I Title: gzf e&Lge7— <br /> I- Name: F <br /> Title: -e ;(Ql A6!Eii :62124- <br /> 2- Name: Marla Oar) <br /> Title:- &v61Lv2 de,�L2�af <br /> 3- Name: it hat it P&fr &K <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 be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: Date: <br /> Title: 4!2-e <br /> Do Not Write Below This Line <br /> IQ) - <br /> R.E.H.S. Application Approval: _�...Oate:1L& Expiration Date: I? <br /> 2 <br /> EH4502 10-03-96 Date Paid 1-)- 2-1- ICD Cash or �ec! 4��5'R�K) (circle) Acct <br />