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Joaquin County Public Health Se es <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To quality for a"Limited Quantity Hauling Exemption" pursuant to the"Medica[Waste Management Ac:', the fallowing <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 /> 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 ,Renewal <br /> Medical Office/Business Name:. <br /> Medical O ice/Business Address: State: Zp Code: <br /> City: Phone <br /> Contact Person: <br /> Storage Facility Name: <br /> Storage acility dress: <br /> State: Zp Code: <br /> City: <br /> Permitted Treatment Facility Name: <br /> Permitted.I(ea ent Faciti Address: State: Zp Code: <br /> City: {gyp <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> Title: ol1 a <br /> 1- Name- Title: <br /> 2- Name: Title: <br /> 3- Name M <br /> • IS l ession at all times wh a traasporcing medical waste. in <br /> A copy of this exem on and a tracking doc a shall i pi genera or h alth care times <br /> fa ing <br /> addition, ail copies of medical waste reco hall be pt 9 <br /> Applicant Signature: <br /> Date: / d <br /> Title: <br /> Do Not Write Below This Line <br /> R.E.H.S. Application Approval: <br /> r Date: _/J`{�Qxpiration Date: 12-131 pZ <br /> EH4302 10-03-96 Date Paid (Z/ D / O/ Cashor Chec< le} Acct—:Go� <br />