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San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Prcgram <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To quality for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Ac;', 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 fallowing: <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 FE. TO: <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> n New Renewal <br /> Medical Office/Business Name:. K'1 C�N� _r <br /> Medical office/Business Address: oa' ' 'U FLA _T t <br /> State. Z:,p Code. <br /> City: S i Phone <br /> Contact Person: <br /> Storage Facility Name: GkibN t I �' <br /> Storage Facility Address: _ State: CA Zip Code: <br /> City: <br /> permitted Treatment Facility Name: <br /> M� ICAL- W/� 5 Lc <br /> \i F 1�,v�.�� o .D <br /> Permitted Treatment Facility Address: r N State: CiI� �rnrti7p Code: <br /> City: <br /> List all employee names and titles authorized to transport the medical waste. if not enough space, attach information. <br /> Title: }"!Eng caL A551 S7Psts T — <br /> 1- Title:_ _ p <br /> 2- Name: <br /> Title: <br /> 3- Name: _Ot-FTtc ��tir �55t:S7P�_ <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, ail copies of medical waste records shall be kept on file at generator's or health care professional's facirity. <br /> Applicant Signature: Date: I a,/ 13 lot <br /> Title: <br /> ��� <br /> Do Not Write Below This Line <br /> 3/IOZ <br /> Date: / Z.Expiration Date: 12-1 <br /> 2.E.H.S. Application Approval: (circle) Acct <br /> :s•:m 'rt(13-96 Date Paidt?- / / 6 Cash or Cnec`< T .5771-7 <br />