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S oaquin County Public Health Se <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION (00/ <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 quantity generator not required to <br /> register pursuant to Chapter 4. <br /> PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH $67 FEE TO: <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> P.O. Box 388 <br /> Stockton, CA 95201-0388 <br /> Medical Waste Hauler Information <br /> ❑ New t Renewal <br /> Medical Office/Business Name: <br /> Medical Office/Business(Address: <br /> City: fjTr V7rr,—& , State: Zip Code: <br /> Contact Person: L Ei LP c-7Lt- Phone <br /> Storage Facility Name: <br /> Storage F cili Addr s: SILL 1 <br /> City: { (� State: Zip Code: <br /> Permitted Treatment Facility Name: 5bf_ <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 /> 1- Name: (. v J, Title: 5 . <br /> 2- Name: Title: r ? <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 /> addition, all copies of medical waste records shall be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: <br /> Title: Date: <br /> Do Not Write Below This Line <br /> - <br /> -Y <br /> Application Approval: Date: 1,2/1fj/%oExpiration Date: / / 9 <br /> EH4502 10-03-96 Date Pai /_-I / 17 Cash or Check# `A (circle) Acct � � <br />