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Joaquin County Public Health Se46es <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTIO <br /> To qualify for a "Limited Quantity Hauling Exemption" pursuant to the"Medical Waste Manage ent Act", the following <br /> conditions must be met: <br /> The generator or health care professional generates less than 20 pounds of medical este per week, transports less <br /> than 20 pounds of medical waste at any one time, maintains a tracking docume 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 organiza on 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 M L WITH $67 FEE 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 /> Medi, al Waste Hauler Information <br /> ❑ New Renewal <br /> Medical Office/Business Name: S r" 6'1 Lid <br /> I U-;9 49- <br /> Medical Office/Business Address: LIV/310®li <br /> City: R State: Zip Code: <br /> Contact Person: Phone#: <br /> Storage Facility Name: Aa<u fled i w flI I., <br /> Storage Facility Address: n <br /> City: IUPC State: Zip Code: f <br /> Permitted Treatment Facility Name: 1 &C Q o e ,* )94P(9 <br /> Permitted Treatment Facility Address: 17=6- t r C <br /> City: :a f-C-QState: Zip Code: <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> A <br /> 1- Name: ro f I=IVI // Title: d7?`1C <br /> 2- Name: cc fl- Title: /n ,D, v u),04(— <br /> 3- Name: Title: <br /> A copy of/thisxemption and a tracking document shall be In employee's possession at all times while transporting medical waste. In <br /> addition, ies of medical waste records shall be kept on file at generator'sor health care professional's facility. <br /> Applicanature: <br /> Title a --Date:—k <br /> Do Not Write Below This Line <br /> R.E. S. Application Approval: Date:___L / Expiration Date: <br /> EH4502 10-03-96 Date Paid / / Cash or Check # (circle) Acct <br /> . a <br />