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S�Joaquin County Public Health Seros <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 /> T <br /> e 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 S67 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 /> Medical Waste Hauler Information <br /> New p'Renewal t <br /> Medical Office/Business Name:. dE ? 5w i fl VM <br /> Medical Office/Business Address: 2-cp"Jf `l '.` <br /> City: State: 0.t`i Zip Cod 2 <br /> _ 52-D <br /> Contact Person: W v N Phone oO <br /> Storage Facility Name: <br /> Storage Facility Addre : <br /> City: State: Zip Code: <br /> Permitted Treatment Facility <br /> Permitted Treatment Facility Address: <br /> City: State: Zip Cade: <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> 1- Name: 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 hansporting medical waste. In <br /> addition, all copies of medical waste records shall be kept on at neratoes or health care professionars Facility. <br /> Applicant Signature: <br /> Title:- Date• >&Z2� / <br /> Oo Not Write Below This Line <br /> R.E.H.S. Application Approval: A41 Date: 2-13/ If Expiration Date: �Z13i 1�0O <br /> EHaso2 10-03-96 Date Paid / / Cash or Chet c T _(circle) Acct <br />