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San-,Joaquin County Public Health Services <br /> Environmental Health Divisio <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify fog­5`Lim'm[fed-Quantity Hauling Exemption" pursuant to the "Medical Waste <br /> Management Act', you are required to meet the following conditions: <br /> 1- Your medical office/business generates less than 20 pounds of regulated medical <br /> waste per week. <br /> 2- Your medical office/business transports less than 20 pounds of regulated medical <br /> waste at any one time. <br /> 3- Your medical office/business maintains records of any regulated medical waste <br /> transported offsite for treatment and disposal, including the quantity of the waste <br /> transported, the type of the waste transported, the date the waste was <br /> transported, the name of authorized person that transported the waste and the <br /> destination of the waste. <br /> PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH $67 APPLICATION FjgY-MTENT <br /> San Joaquin County Public Health Services JUN 6 1996 <br /> Environmental Health Division SAN jUAOUIi\j�,Uujjy <br /> P.O. Box 388 ;7W <br /> Pe PUBLIC HEALTH SERVICES <br /> Stockton, CA 95201-0388 Vr~.r1W- ENVIRONMENTAL HEALTH DIVISION <br /> Medical Waste Hauler Information <br /> Medical Office/Business Name: <br /> MedicI Office/Business Address: <br /> City: u(NI State: C, Zip Code: <br /> Contact Person- C-h Phone <br /> Permitted Treatment Facility Name: Permit <br /> Permitted Treatment Facility Address:) <br /> J State:_r_-d Zip Code <br /> Please list employee names and titles authorized to transport the medical waste. <br /> 1- Name: Q SLoj k)K- D-(\n Title: <br /> 2- Name:j!j0e.ri' 01-1-ri non, Title: <br /> 3- Name: !a <br /> \-QL, 7 t1e: <br /> If transporting medical waste to a permitted storage facility for consolidation purposes or if veterinarian or <br /> e health care nurse transporting medical waste back to own facility, please complete the following: <br /> Storage Facility Name: Permit <br /> Storage Facility Address: <br /> City: -State: _Zip Code: <br /> A copy of this exemption and a tracking document containing the information above shall be in <br /> employees possession at all tites while Ttraspob sporting medical waste. In addition, all copies of <br /> r. a" <br /> medical waste re s sha be it if t our facility. <br /> COT, Title: Date: <br /> Applicant Signature: <br /> R.E.H.S. Application Approval Date: <br /> EH 45 02 09-27-95 <br />