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San Jin County Public Health Services; <br /> ironmental 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 <br /> Environmental Health Division (copy Medical Waste Management Program <br /> P.O. Box 388 <br /> Stockton, CA 95201-0388 <br /> Medical Waste Hauler Information <br /> ❑ New M Renewal <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: 1 o Y«A /-7., <br /> City: State: to Zip Code: 95--766 <br /> Contact Person: A414—,l Phone #: 2,o 19,;-vz�. <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> City: State: Zip Code: <br /> Permitted Treatment Facility Name: D, _ JVI �l•�<I <br /> Permitted Treatment Facility Address: !44( J=I..•J, 4L-t <br /> City: yM-ills )~ State: cA Zip Code: <br /> List all employee names and <br /> /titles authorized to transport the medical waste. If not enough space, attach information. <br /> 1- Name: Title: <br /> 2- Name: Tom- Title: /t&-v, <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, ail 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: 9g <br /> Do Not Write Below This Line <br /> R.E.H.S. Application Approval: Date: / /,X Expiration Date: I / 9 <br /> EH4502 10-03-96 Date Paid r /14,2 Cash or ec (dircle) Acct <br />