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San Joaquin County Public Health Services Environmental Health Divisi Medical Waste Management Prow ram APPLICATION FOR A LIMITED UANTf :U1 19XEMPTION To qualify fora "limited Quantity Hauling Exrr nl~ u the "Medical Waste Management Act", you are required t et the following condi ions: 1- Your medical office/business generates less than 20 pounds of regulated medical waste per week. 2- Your medical office/business transports less than 20 pounds of regulated medical waste at any one time. 3- Your medical office/business maintains records of any regulated medical waste transported offsite for treatment and disposal, including the quantity of the waste transported, the type of the waste transported, the date the waste was transported, the name of authorized person that transported the waste and the destination of the waste. PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH $67 APPLICATION FEE TO: San Joaquin County Public Health Services Environmental Health Division P.O. Box 388 Stockton, CA 95201-0388 Medical Waste Hauler Information Medical Office/Business Name: L Medical is us'ness Address: 0 City: I State: Zip Code: 070 Contact Person: Phone ya- Permitted Treatment Facility Name: Permit#: Permitted Treatment Facility Address: City: State: Zip Code: Please list employee names and titles authorized to transport the medical waste. 1- Name:Z,fi//A we'e C ®Title: YMAe, 2- Name: .5 Title: 3- 1 eg2z Title: If transporting medical waste to a permitted storage facility for consolidation purposes or if veterinarian or home health care nurse transporting medical waste back to own facility, please complete the following: Storage Facility Name: lag6 A21gle Permit#: Z2 Storage F cility Aodress: City: State: Zip Code: S ' A copy of this exemption and a tracking document containing the information above shall be in employees possession at all times while transporting medical waste. In addition, all copies of medical waste records shall be kept on file at your facility. ,A Applicant Signature: Title: Date: R.E.H.S. Application Approval: Date: EH 45 02 09-27-95