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San7oaquin County Public Health Servi <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 Acct% 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 ZO 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 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 F Renewal <br /> Medical Office/Business Name: St. Jose h° s Commun' <br /> Medical Office/Business Address: <br /> State: CA Zp Code:9 5 21 9 <br /> City: Phone <br /> Contact Person: <br /> Storage Facility Name: ' <br /> Storage Facility Address: 740 Slate:CA Zip Code: Qr,-)1 A <br /> City: Stockton <br /> Permitted Treatment Facility Name: St Joseph ' n M dical Pnter <br /> Permitted Treatment Facility Address: 1800 p <br /> State: Tp Code: A r,9 n 4 <br /> City: Stockt <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> Titre: RN A mi n; S.t-ratnr <br /> car-1- Name: <br /> nn ,- ' .�,-; o FarrF+l 1 Title: RNA r'1 i ni cal qu c�rv; <br /> Title: <br /> 3- Name:���.] u; t-c-hc`oc�k <br /> A copy of this exemption and a tracking document s U be in employee's possession at all times while traruporting medical waste. in <br /> addition, all copies of medl wassm ords sha b kept on file at generator's or health care professional's facility. <br /> Applicant Signature: <br /> Date: <br /> Title: Administrator <br /> Do Not Write Below This Line <br /> 2.E.H.S. Application Approval: Date: / /00 Expiration Date: 13 10 <br /> i Ha5o2 10-03-46 Dace ?aid `� !?'y/00 Chece <br /> /3�OZ (circle) Acct �Z <br />