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SANOAQUIN COUNTY PUBLIC HEALTH VICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EDMN=ON <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 transported, <br /> the name of authorized person that transported the waste and the destination of the <br /> waste. <br /> PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH$67 APPLICATION FEE <br /> TO: <br /> San Joaquin County Public Health Services <br /> Environmental Health Division (C(DPY P.O. Box 2009 <br /> Stockton, CA 95201 <br /> Medical Waste Hauler Information <br /> Medical Office/Business Name: LA VeAe.ri^ae-Ji P t t'i s'k4 kiiel7t, <br /> Medical Office/Business Address: - C I( ,✓ 2 <br /> City; f� State; Tip Code: SZ Z D <br /> Contact Person: PctAj .n.,7cic V V r 1 Phone #: Z09 7 3353 <br /> Permitted Treatment Facility Name: Permit #: <br /> Permitted Treatment Facility Address: <br /> City: Stag: Tap Code: <br /> Please list employee names and titles authorized to transport the medical waste. <br /> 1- Name: o H P-- Title: <br /> 2- Name: Title• <br /> 3- Name: Title- <br /> If transporting medical waste to a permitted storage facility for consolidation purposes or if veterinarian <br /> or home health care nurse transporting medical waste back to own facility, please complete the following: <br /> Storage Facility Name: wr Ve -Se- e Permit #1 <br /> Storage Facility Address: /Y'SFr 7 C, Cel(t s/ rccl <br /> City: Ak-a�a State: C-A— Zip Code: 9-5 7-Z d <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 sh be pt y r1acility. <br /> Applicant Signature: Title: 61cuAtZt/' Date: <br /> R.E.H.S. Application Approval: Zmv, Date: <br /> EH 45 02 12-2-91 V <br />