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S•Joaquin County Public Health Sees <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 qu tity ator not required to <br /> register pursuant to Chapter 4. <br /> PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH $67 FEE TO: o <br /> San Joaquin County Public Health Services _ <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> P.O. Box 388 DEC 131996 <br /> Stockton, CA 95201-0388 <br /> El New 10CRenewal NP0,E. <br /> Medical Waste Hauler Information zNV;R TIAL HEALTH <br /> T <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: k <br /> City: State: I✓F�lf Zip Code: U <br /> Contact Person: (� hr,—, r if N r'r"C) Phone#: <br /> Storage Facility Name: I od _I 1&1u�l11 <br /> Storage Facility Address: 24 r 0,\1 <br /> City: Lc.1 State: CPr Zip Code: gS24fZ_ <br /> Permitted Treatment Facility Name: 6j-I'C.r-i G CkQ <br /> Permitted Treatment Facility Address: lb�v +�c <br /> City: - R — eP 61 aM 0 5 State: C Zip Code: g z 3�y <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> 1- Name: Title: <br /> 2- Name: Title: <br /> 3- Name: Title: <br /> A copy of this exemption a d a tracking document shall be in employee's possession at all times while transporting medical waste. In <br /> addition, all copies of med1 waste recorc�sl shat be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: <br /> z� <br /> Title -,) Date: <br /> V <br /> Do Not Write Below This Line <br /> R.E.H.S. Application Approval: Date: / / Expiration Date: <br /> EH4502 10-03-96 Date Paid 13 J qt o Cash �heck 10 5D? (circle) Acct <br />