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Saoaquin County Public Health Serv* <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 Ac:', 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 $67 FE'E TO: <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> 0 New X Renewal <br /> Medical Office/Business Name: <br /> SDS , p V rti'1 <br /> Medical Office/Business Address: S ?tom �� State: Zp Code: �3 <br /> City: ' Si= + Phone T S X55 �`J X21 <br /> Contact Person: ff,2 <br /> Storage Facility Name: <br /> Storage Facility Address: State: _ Zo Code: <br /> City: E4 <br /> Permitted Treatment Facility Name: f <br /> Permitted Treatment Facility Address: State: Zp Code: <br /> City: <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> N/ <br /> 1- Name: Title: <br /> 2- Name: Title: <br /> 3- Name: <br /> A copy of this exemption and a tracking document shall be in employee's at generate s(,possession <br /> sionat alth ail <br /> ti es whit i transporting medic <br /> waste. in <br /> addition. all copies of medical waste records shat! b <br /> Applicant Signature: Date: l�- <br /> Title: <br /> Do Not Write Below This tine <br /> R.E.H.S. Application Approval <br /> ate: __e at'w ate• I I <br /> EH4502 10-03-96 Date Paid / / SIO! Cash 06$` 0 9 (circle) Acct <br />