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Woaquin'County Public Health S <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 /> I- 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 <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> V New 0 Renewal <br /> Medical Office/Business Name: Viioi Link Lcri*, inc dbg U Fol L.oL 8cme Heatill Core <br /> Medical Office/Business Address: i i k L)r,m r <br /> 5,:.Ft A <br /> City: 5l­cckfc-r, State: L"A Zip Code: 85'207 <br /> Contact Person:. LQhietn Krur.Qer Phone#:2c9 15L Si 3V <br /> Storage Facility Name: VLial Link Hnmr. Heajfh LLC <br /> Storage Facility Address: H744 Qua Loke•i Dri.e, Sui I­& A <br /> City: Slcak+ca State: C^ —Zip Code: 2520,1 <br /> Permitted Treatment Facility Name: InEgac Fed Envirc-amcaicl <br /> Permitted Treatment Facility Address: 424 Hi + <br /> City: oaklaflrj State: CA Zip Code: q41,ol <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> 1- Name: Kio+hle-en Krut-Qg!r Tittle: RN C <br /> 2- Name: judo H c i� rj Title: K M <br /> 3- Name: L�'Cc, Pcinz� tos Title: R H - <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 an file at generator's or health care professional's facility. <br /> Applicant Signature: _--�C�Lzez_2 <br /> Date: L <br /> Title: <br /> Do Not Write Below This Line <br /> , 7 _7�j , <br /> R.E.H.S. Application Approval. ADate: Expiration Date: 1,511 <br /> 7 <br /> EH4502 10-03.96 Date Paid C 1,5 h r Check .4 (circle) Acct <br />