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San*quin'County Public Health Servide <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 cop <br /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> ❑ New iRenewal <br /> Medical Office/Business Name: C c' <br /> Medica Office/Business Address: <br /> City: acd 14 <br /> State: ; Zip Code: <br /> Contact Person: Phone #: �i <br /> Storage Facility Name: A 17 k(z. I <br /> Storage Facility Address: zQL4 <br /> City: �.k,C , � _State: Zip Code: <br /> Permitted Treatment Facility Name: "5W, s. <br /> Permitted�at nt Fac"ty Address: � - -' <br /> City: t�� State: Zip Code: <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> 1- Name:. () ..S / Title: <br /> 2- Name: ► v7 Title:_--- 6/)- /t <br /> 3- Name: Title: / 0 SLrc �� 5 <br /> A copy of this exemption�d a tracks doc t shall btnfile <br /> mployee's possession at all times while transporting medical waste. In <br /> addition, all copies of medical waste r _)r <br /> all e kepat generator's or health care professional's facility. <br /> Applicant Signature- <br /> Title: Date: f / <br /> Do Not Write Below This Line <br /> R.E.H.S. Application Approval: 17,9,'t,. 1 Date: ^- "1'-Expiration Date: =l I <br /> EN4502 1403-96 Date Paid ' / / R Cash or Check # —20 (circle) Acct <br />