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10,oaquin County Public Health Se los <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 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 Q <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> 0 New t Renewal <br /> Medical Office/Business Name: <br /> Medical Office/Bus 4ns Address:City: � � _State: K� Zip Code: ,5a0.2- <br /> Contact Person: k4 6f,e 601 <br /> u><nJ Phone#:oZ49 6�3.Z 5 <br /> Storage Facility Name: <br /> Storage Facili Address: 44/ e2 r <br /> City: 6 ok--74iy✓ State: � Zip Code: �o <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: /�l 19, Cel7A',— <br /> City: � L' yy State: Zip Code: L� <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> 1- Name: a SP Title: <br /> 2- Name: 6 Title:_LV _ <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 cords s be kept on file at ge(n�eratoes or health care professional's facility. <br /> Applicant g licant Si nature: Auc �6cd — <br /> Title er , Date: /-L-/ 16197 <br /> Do Not//Write Below This Line - <br /> R.E.H.S. Application Approval:—, V, Date: piration Date 1.3/ / <br /> EH4502 10-03-96 Date Paid t / Cash or Check# (circle) Acct <br />