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Saquin County Public Health Servift Onvironmental Health Division Medical Waste Management Program APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION To qualify for a "Limited Quantity Hauling Exemption" pursuant to the"Medical Waste Management Act", the following conditions must be met: The generator or health care professional generates less than 20 pounds of medical waste per week, transports less than 20 pounds of medical waste at any one time, maintains a tracking document pursuant to Chapter 6, and the generator or parent organization has on file one of the following: 1- Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a small quantity generator required to register pursuant to Chapter 4. 2- Information Document if the generator or parent organization is a small quantity generator not required to register pursuant to Chapter 4. PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH $67 FEE TO: San Joaquin County Public Health Services Environmental Health Division C cc)�Pl Medical Waste Management Program 304 E Weber Ave Stockton, CA 95202 Medical Waste Hauler Information ❑ New �(Renewal Medical Office/Business Name: x'74 I L7f! p,..r ` I Pt 'ri Medical Office/Business Address: f S' City: STC�Ci f`r.� State: 0 Zip Code: S� D Contact Person: 5 A2A t'So'b .tl.,� _ Phone #: - ��?) Storage Facility Name: qt -A C Storage Facility Address: L1 14 City: SRtk- .t� _State: CAZip Code: �1SaC+ Permitted Treatment Facility Name: LTn 6k4La Permitted Treatment Facility Address I0 r) 'P -�-�- S?. City:_ SiaCICV�) State: r,4- Zip Code:_ 19,5-Q6:1 List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. 1- Name: t5AR-P GC-0ci'1u) Title: tiP ►2 OFCL/a:<Ae- 2- Name: fr f4 R-S� S c:TA) sem Title: A 11 3- Name: Q t)9-(5;^j i rI- Al i t_i-a l Title: A)P A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In addition, ail copies of medical ste records shall be kept on file at generator's or health care professional's facility. Applicant Signature: 'a-= Ck G Q Ax Title: - �i L� Date: Do Not Write Below This Line R.E.H.S. Application Approval: r ! ,,i /-7,a'! _ Date: , 1 / Expiration EH4502 to 03-96 Date Paid' / / D J Cash or Check #�� (circle) Acct