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San Juin County Public Health Service* <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> TQ qualify-f�r 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 /> ` f ME x <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program (C(Dpy <br /> DEC 131996 <br /> P.O. Box 388 -K ACU <br /> Stockton, CA 95201-0388 P'jSL;C HEALTH SERVICES <br /> ENVIRCNMEry AL HEALT.�-4 _j�y:,^inn: <br /> Medical Waste Hauler Information <br /> ❑ New J�,Renewal <br /> Medical Office/Business Name: ,L r- 9I A-d I C(fA k <br /> Medicalffice/Business Address: r ' non <br /> City; anle State: Zip Code: <br /> Contact Person: Sl o Phone <br /> Storage Facility Name: 1 W &— <br /> Storage Facili Address: ~© /�, d/1 <br /> City; State: Zip Code: <br /> Permitted Treatment Facility Name: (" <br /> Permitted Treatment Facility Address: <br /> City: �'1nr �Q���. State: Zip Code. <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> 1- Name: K) F I Title: <br /> 2- Name: V t-• CLQ 4d, u-1 4-, Title: rn I —0 a) t),- <br /> 3- <br /> )P3- 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: t 2- / t( / <br /> Do Not Write Below This Line d <br /> R.E.H.S. Application Approval: _ Date: ? /97—Expiration Date: l <br /> EH4502 10-03-96 Date Paid /12—/ /3 /14 Cash or C�e 4L� (circle) Acct !,4'd <br />