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San Joaquin County Public Health Services <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 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 /> 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 /> 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 NewZbRenewal <br /> Medical Office/Business Name, Manteca Unified School Dist-ri <br /> Medical Office/pusiness Address: Post Office Box 32 2901 East Louise Avenue-Manteca State: C,& Zip Code: 95336 <br /> Contact Person: Phone 11r. 825-3200 x782 <br /> Storage Facility Name: Integrated Enviornmental systim—s <br /> Storage Facility Address:-499 High Street State: CA ---Zip Code: 94601 <br /> City: Oakland <br /> Permitted Treatment Facility Name* <br /> Permitted Treatment Facility Address: —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 /> I- Name: see attachment Tiift. <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,be kept an Rig at generator's or health care professional's facility. <br /> Applicant Signature: <br /> Title: Coordinator of health Services Date: 03 / 0 01 <br /> Do Not Write Below This Line <br /> R.E.H.S. Application Approval: Date: Expiration Date:_- <br /> EH4502 10-03-96 Date Paid Cash or Check W- (circle) Acct___----;-- <br />