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I <br /> SjOloaquin County Public Health Servs <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 or medical waste at any one time, maintains a tracking document pursuant to Chapter 6, and the <br /> generator or parent organization has an file one of the fallowing: <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 A&N'D MAIL WITH S67 F=E 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 /> Medical Waste Hauler Information <br /> ❑ New X Renewal <br /> Medical Office/Business Name: TE�S�� D v rel <br /> Medical Office/Business Addres�s`El 15 N 11W q -52- <br /> City: ;1 rr tee, tDe- 6P,)\J0 State: Zp Code: 53 3L,2- <br /> Contact Person: ('ri`1 L5 /-6b Phone 3 $5 "11;21 <br /> Storage Facility Name: <br /> Storage Facility Address: <br /> City: State: Zip Code: <br /> Permitted Treatment Facility Name: 0 - <br /> Permitted Treatment Facility Address: <br /> State: Zip Code: <br /> City: <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> 1- Name: 1 Title: <br /> 2- Name: Title: <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 records shall b wmynfle at generator's or health care professional's facility. <br /> Applicant Signature: <br /> Date: 1��� /-191on <br /> Title: <br /> j�Do Not Write Below This Line <br /> Q.E.H.S. Application Approval -J �'�'7 Date: / �' /Ol Expiration Date: <br /> EH4502 10-03-96 Date Paid / S / 01 Cash o Chec< s l i7 9 (circle) Acct <br />