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S oaquin County Public Healthices <br /> Environmental Health Divisio <br /> Medical Waste Management Program <br /> 1 <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION ' <br /> To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical W/(gt83 <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 APPLICATIC VWj Epj <br /> San Joaquin County Public Health Services <br /> Environmental Health Division JUN 17 1996 <br /> P.O. Box 388 SAN,, <br /> Stockton, CA 95201-0388 PUSLIC HEALTH SE <br /> N'VICcS <br /> cNVIRONMENTqL HEALTH VISiOn,; <br /> Medical Waste Hauler Information <br /> Medical Office/Business Name: 4 /� L 1l <br /> Medical f� c usiness Address: ,� <br /> City: , �/ State: Zip Code. 010 <br /> Contact Person: Phone#:0209- -6 <br /> Permitted Treatment Facility Name: Permit#: <br /> Permitted Treatment Facility Address: <br /> City: State: Zip Code: <br /> Please list employee names and titles authorized to transport the medical waste. <br /> 1- Name: d/Q/� ,e C ,eiV Title: <br /> 2- Name: S �' Title: /� /� <br /> 3- Name: <br /> If transporting medical waste to a permitted storage facility for consolidation purposes or ifveterinarian or <br /> home health care nurse transporting medical waste back to own facility, please complete the following: <br /> Storage Facility Name: 166 Isle Lle,19 f�oG Permit#: /17— <br /> Storage F cili A dress: / <br /> leelfll 4-r <br /> City: Z S State: Zip Code: S <br /> A copy of this exemption and a tracking document containing the information above shall be in <br /> employees possession at all times while transporting medical waste. In addition, all copies of <br /> medical waste records shall be kept on file at your facility. <br /> Applicant Si , <br /> pp Signature: / Title: Date: <br /> R.E.H.S. Application Approval. Date: <br /> EH 45 02 09-27-95 <br />