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San4win County Public Health Servi ft <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 cane 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 /> 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 F1=E Tn — <br /> San Joaquin County Public Health Services Post41V Fax Note 7671 Date 3 pages® <br /> Environmental Health Division it ' From �o <br /> Medical Waste Management Program Co./Dept. Co. <br /> 304 E Weber Ave Phone# Phone# <br /> Stockton, CA 95202F # g®�39 Fax# g- 34.33 <br /> Medical Wast&-ri,&umr­tnTc;rMaU0ne <br /> New Q Renewal <br /> Medical Office/Business Name: CL/Nt cA L jyE LTi/ ,40 P i2A i SA LS. -=6K <br /> Medical Office/Business Address: ?/(a U -ST-.- <br /> City: <br /> ST-City: S<}rIaa2Ed7n State: C A -Zip Code: 9 8l <br /> Contact Person:�M 1lc n rro Phone* (_ 9/6)y 7- <br /> Storage Facility Name: _IArIrhL LFE'aLTu ApejgAirkLS Z:d c <br /> Storage Facility Address: ,2�/(a I/ <br /> City: S A CRA02 nrrn _--- State: Zip Code: I.M? <br /> Permitted Treatment Facility Name: ;sr=r – jzr= ®fjj/ W&S-4 <br /> Permitted Treatment Facility Address: ? r' c RaCg <br /> City:, Rar►ctio Cordov4, State: 111 Zip Code: IS6 70 <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> 1- Name: o2Eia Title: Presidd,"�- <br /> 2- Name: Tide: sv A rte h'Icr vgj cr <br /> 3- Name: Title: <br /> A copy of this exemption and a tracking document shall be in em 's possession at all times while transporting medical waste. In <br /> addition, all copies of medical waste records shad be kept on file at generator's or health care professionaft facility. <br /> Applicant Signature: <br /> Title: / MAi2tS&dC Date: <br /> Do Not Write Below This Line <br /> R.E.H.S. Application Approval--'–. / 7s -Date:_V/ Z /`fExpiratian Date: ZZ1 <br /> EH4502 10-03-46 Date Paidl I q / c''1` h or e� 7 �5-/ (circle) Acct <br />