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n Joaquin County Public Health Se t ces <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 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 <br /> Environmental Health Division <br /> Medical Waste Management Program (COF)y P.O. Box 388 <br /> Stockton, CA 95201-0388 <br /> Medical Waste Hauler Information <br /> ❑ New.yRenewal <br /> Medical Office/Business Name: Nlfl r /(lC <br /> Medical Office/Business Address: o2fO,�(v Pi '- !0• 77 <br /> City: J� State: C/9- Zip Code: 5-Z v <br /> Contact Person: 9YL5 Phone #: —44 7�O <br /> Storage Facility Name: <br /> Storage Facility Address: 701 F 7 7 <br /> City: State: CA— Zip Code: <br /> Permitted Treatment Facility Name: 4FD /n <br /> Permitted Treatment Facility.,Address: Q-[1 dI <br /> City: /I AA4111 nAn _State: Zip Code: R 5 y Z <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> 1- Name: A", Pry Title: 1(, <br /> 2- Name: MANWwxs Title: (/�- <br /> 3- Name: Qx Titte: <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 wast reco s shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: <br /> Title: T11eC*)'.. a Date: �2-/ /60 / <br /> Do Not Write Below This Line <br /> R.E.H.S. Application Approval: 6Date: / g / expiration Date: <br /> EH4502 10-03-96 Date Paid Cash or Check #.302?7 (circle) Acct�f- <br />