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0Joaquin County Public Health S�ices Environmental Health Division O Medical Waste Management Program (C , APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION To qualify for a "Limited Quantity Hauling Exemption" pursuant to the"Medical Waste Management Act', the following conditions must be met: The generator or health care professional generates less than 20 pounds of medical waste per week, transports less than 20 pounds of medical waste at any one time, maintains a tracking document pursuant to Chapter 6, and the generator or parent organization has on file one of the following: 1- Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a small quantity generator required to register pursuant to Chapter 4. 2- Information Document if the generator or parent organization is a small quantity generator not required to register pursuant to Chapter 4. PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH $67 FEE TO: San Joaquin County Public Health Services Environmental Health Division Medical Waste Management Program P.O. Box 388 Stockton, CA 95201-0388 Medical Waste Hauler Information ❑ New ® Renewal Medical Office/Busigess Name: Fi rgr AmPri ran Hnma r.a,-A of S_tcaClrtoaz Medical Office/Business Address:2453 Grand Canal Blvd. , Suite C. Stockton, CA 95207 City: Stockton State: CA Zip Code: 95207 Contact Person: Patty Rizzotti-Hughes/Stefanie Rabe Phone#: 209/957-2100 Storage Facility Name: First American Home Care Storage Facility Address: 2453 Grand Canal Blvd. , Suite C City: Stockton State: CA Zip Code: 95207 Permitted Treatment Facility Name: BF1 medical waste Systems Permitted Treatment Facility Address: 4135 W. Swift Ave. City: FrP.S'no State: CA Zip Code: 93722 List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. 1- Name: See Attached Sheet Title: 2- Name: Title: 3- Name: Title: A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. in addition, all copies of medical waste records shall be kept on file at generator's or health care professional's facility. Applicant Signature: Title: Date: Do Not Write Below This Line Gni R.E.H.S. Application Approval: Date: /moi Expiration Date: r//ee / -� D EH4502 10-03-96 Date Paid / / k0 Cash o Check #�'q"� (circle) AcctJt`JV