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9-04-1998 4:35PM FROt <br /> P. 2 <br /> &n Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Prcgram <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for a "Limited Quantity Hauling Exemption" pursuant to the"Medical Waste Management AG", 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 5, 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 G Renewal <br /> Medical C`fice./Business Name: 57 ?SYv�r�-�-I- t ((UV12Si <br /> Medical Office/Susiness Address: N. 1 Aj r <br /> CIty: stmg=k�__ x State; Zip Code:-':?5-ao <br /> Contact Person:_ 1011U.,nA Phone _20� (0* g� <br /> Storage Facility Name: ST- S ' �` C ALl- A_QSrr-r, � <br /> Storage Facility Address: 4 0'7 �-- <br /> City:. Zip Code: <br /> Permitted Treatment Facility Name: �r 5, <br /> Permitted Treatment Facility Address: F t-f -t- <br /> City: G l �Q state: Z¢ Code: <br /> List all employee names and titles authorized to transaort the medical waste. If not enough space, attach information. <br /> I- Nave: -� 1���� , Tit;e: r2-N �rly%,/vIS�i�.l� c/L <br /> 2- Name:�a°rrV\ � � Title: Gl i,v t due+ r vn <br /> 3- Name: SL)S i- ^ Title: 1: <br /> '4ryL tae_ X- <br /> A copy of thls exemption and a tracking doeum shalt be in o mployee's possession at ail tunes wra7e trans <br /> A 9 medical waste. In <br /> addition, all copies of medical waste records shalt be <br /> kept an file at generator's or health eats professJami's faciiiiy. <br /> Applicant Signature: <br /> Title.- rZG\l N I C4-st�(\ Date: <br /> Do Not Write Below This Line <br /> R-E.H.S. Application Approval: X 1::;Z_ <br /> Date /'� / piration Date:CS /;2-/ 31 <br /> / <br /> EH4502 1"3-96 Date Paid y 64 / �� h or Check /0/3 (circle) Acct -7 <br />