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San Joaquin County Public Health Se ices <br /> Pedinvironmen I Health Division <br /> cal Waste Management Progra <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for a "Limited 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 FEE TO: <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> P.O. Box 388 <br /> Stockton, CA 95201-0388 <br /> Medical Waste Hauler Information <br /> Medical Office/Business Name: ` E4.1� 4LT CA-R <br /> Medical Office/Business AQ-A)9: <br /> City: f iocictd,6 _ State: C4 Zip Code: 9S9LOTZ <br /> Contact Person: SPPA 0&4j,'a Qti P _P hone o2a9 ) 466 <br /> Permitted Treatment Facility Name: FA774 C Aag Permit* 00,245 <br /> Permitted Treatment Facility Address: e// ,/ lt/• Ccs STi2FF'7- <br /> City: 5 zZ_/cro A) State: CA Tip Code: 9,5'a L'2 <br /> Please list employee names and titles authorized to transport the medical waste. <br /> 1- Name: A l k P_7 A),ES S Title: IU P <br /> 2- Name: —4,1 /., Tstle: SUP <br /> 3- Name: sq. 2A Caoj)"21A) Title: A) I) ;2 OF QA 1,d21C'AG S�2u'ieFS <br /> If transporting medical waste to a permitted storage facility for consolidation purposes or if veterinarian or <br /> home 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 times while transporting medical waste. In addition, all copies of <br /> medical waste records shall be kept on file at your facility. <br /> Applicant Signature: Otc0- CC(/LkA-.4� A)19 Title:�be. 6tFC�iiAA46 is Date: <br /> R.E.H.S. Application Approval: Date: . <br /> EH 45 02 09-27-95 � ��ltu(94 <br /> �C'I+ <br />