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Sanquin County Public Health Servic* <br /> nvironmental Health Division <br /> Medical Waste Management Program (C <br /> [� <br /> )Y <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTI <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 <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> 0 New Woenewal <br /> Medical Office/Business Name: - l9 <br /> Medical Office/Business Address: L� <br /> City: State: l'ff Zip Cade: !� <br /> Contact Person: Phone #: <br /> Storage Facility Name: <br /> Storage Faci1*ip Address: dZ 5 Lv; <br /> City , , State: Zip Code: <br /> Permitted Treatment Facility Name: 6-he-6 c tte— <br /> Permitted Treatment Facility Address: 033C) <br /> City: Ian&Ia,tiIjS State: (-'A— Zip Code: 3 <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> 1- Name: no 1n Title: <br /> 2- Name: Title: <br /> 3- Name: Title: <br /> A copy of this exemption and tracking document shall be in employee's possession at all times while transporting medical waste. In <br /> addition, all copies of medl I records kept on file at generator's or health care professional's facility. <br /> sha <br /> Applican Si n ture: -ZZ: - <br /> TitlDate: —2 / / <br /> Do Not Write Below This Line » <br /> R.E.H.S. Application Approval: . Date: / I xpiration Date- / / <br /> EH4502 1003-96 Date Pais1 / 23/ �"i' Cash or eck JQ _(circle) Acct • <br />