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S oaquin County Public Health Seros <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 /> 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 S67 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 /> Q New Renewal <br /> Medical office/Business Name: <br /> Medical O ce/Business Address: State: Zip Code: <br /> City: n Phone ''. <br /> Contact Person: <br /> Storage Facility Name: l 1 <br /> Storage Facility Address: <br /> City: �. d , <br /> State: Zip Code: a? <br /> Permitted Treatment Facility Name. <br /> Perini Tr atment cility Address: State: /IjA- _ .Zip Code: <br /> City: <br /> to transport the medical waste. If enough space, attach information. <br /> List all employee names and titles authorized <br /> Title: <br /> MCI- <br /> I- Name: _ Title: <br /> 2_ Name: Title: <br /> 3- Name: <br /> & - - - (i <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while tramporting medical waste. in <br /> add edical waste records shad be kept on file at generator's or health care professional's facility. <br /> plicant Si e' <br /> Oate: ! ! <br /> Do Not Write Below This Line, <br /> Q.E.H.S. Application Approva ate: / / �Expi3ration Oate:� <br /> EHa5o2 too3-96 Date Paid (L/ !Ip ! d Cash Chedk � 3 � icirgcf� Acct <br /> c( Y06 (((,r7) <br />