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San Akin County Public Health Service* <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 he 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 S67 FEE TO: <br /> San Joaquin County Public Health Services <br /> Environmental Health Division D(0 <br /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> 0 New XRenewal <br /> Medical Office/Business Name: CAc 14c-: &LT WC, <br /> Medical Office/Business Address: H Qes(iso c I-c- C_ <br /> City: S Z 6 k r6 State: CA Zip Code: 9S.ZQ-7 <br /> Contact Person: U l U [A-1,J UDELICK, (Z ls� Phone;t �aa e17=5 <br /> I <br /> Storage Facility Name: -7 7 77 7 P-A ,-D iE fJ U I R 01J kA 4 N `i — 5 K&LEM 5: <br /> Storage Facility Address: rf /L6'(11 S-6 <br /> City: D i4 k I-A OJ T> State: CA, Zip Code. <br /> Permitted Treatment Facility Name:----,61" <br /> Permitted Treatment Facility Address: <br /> City: State: Zip Code: <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information.' <br /> I- Name: Title: <br /> 2- Name: Title: <br /> 3- Name: Title: <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. in <br /> additlon, all copies of medical waste re rds shall be kept on file at generator's or health care prohnsionars facility. <br /> Applicant S* n t <br /> Title: <br /> VW Date: + <br /> Do Not Write Below This Line <br /> R.E.H.S. Application Approval:Z944,Y Expiration Date: Z/ /7000 <br /> EH4502 10-03-96 Date Paid) (circle) Acct <br /> —Li/ f�0 � er Cash o Check <br />