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11/03/2000 11:45 2093433 FIFTH FLOOR9 PAGE 02 <br /> San 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 Mauling Exemption" pursuant to the-Medical Waste Management Ac:', the fallowing <br /> candlbons must be met <br /> The generator or health acre professional genertes less then 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 fife one of the following <br /> 1_ Medical Waste Management Plan if the generator or parent organization is a targe quantity generator or a s.-nail <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 /> PLF-ASE COMpLE—,= THE INFORMATION BELOW AND MAIL WITH $87 FEE TO: <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> 304 E Weber Ave �y <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> New G Renewal <br /> 73 <br /> Medical Offics/Susiness Name: ®� I -- <br /> [12r <br /> Medical Offrce/B usiness Address: : pe f- Statr:: Zip Code: <br /> City: _ Phone <br /> Contact Person. "' <br /> Storage Facility Name: <br /> Storage Facility Address: State_,= P Cie: <br /> City: <br /> Permitted Treatment Facility name: <br /> Permitted Treatment Facility Address: Cade: <br /> City: State: � ® P <br /> WMEMOMMO <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, <br /> attach information. <br /> \ Title: �tJ NL iy C� °R <br /> I- Name: �LLPE � <br /> 2- Name: ,C[_ Title: <br /> 3- Name: <br /> c Ltd 'title: <br /> A copy of this exemptlan and a tracking document shall be in emplayee's pression at all*ves wh7e trw PortW9 medrezi waste. In <br /> adc�tlon. all eoples of medical n:carcLs strati be leapt an fila at gece3rator's or health care ProfassionaPs facility. <br /> Applicant Signature: ate=/Z=/ <br /> Title: <br /> Do Not Write BelowThis Line <br /> Q.E.H.S. Application Approval: <br /> r Date:�L iration Date:l3� <br /> EH4502 1"3-96pate Paid / OC7 Casa or Chedc z_� ! tcircie? Act <br />