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San Awn County Public Health ServiC=SO <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 Actt% 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 fife one of the following: <br /> Medical Waste Management Plan if the generator or parent organization is a large quantity genehator 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: PAYMENT <br /> San Joaquin County Public Health Services RECEIVED <br /> Environmental Health Division JAN 15 2003 <br /> Medical Waste Management Program <br /> 304 E Weber Ave SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> Stockton, CA 95202 EWIRTN10ENTXL hll,:�!_TH Y:�Sl \ <br /> Medical Waste Hauler Information <br /> 0 New I&Renewal <br /> Medical office/Business Name:__ <br /> Medical Office/Business Address:-- <br /> State:- Zip Code: <br /> City: k- Phone t <br /> Contact Persone e <br /> Storage Facility Name:— <br /> Storage Facility Address: State: C <br /> ,8= _Zip Code: 4k,; <br /> City: <br /> Permitted Treatment Facility Name: f <br /> Permitted Treaftdnt Facility Address: <br /> State: Zip Code: <br /> City: U <br /> List all employee names and titles; authorized to transport the medical waste. If not enough space, attach information. <br /> I- Name: Tide: <br /> Title: <br /> 2- Name: Title: <br /> 3- Name: <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. in <br /> addition, all copies of medN I waste records shall be kept on file at generators or health care professional's facility. <br /> Applicant Signature: Date:_1_/ 02�� <br /> Title: <br /> Do Not Write Below This Line <br /> ------------------- <br /> R.E.H.S. Application Approval: <br /> Date: �110 Expiration Date: <br /> Date <br /> Cash otr<, (circle) Acct <br /> EH4502 1"3-96 Date Paid ash ot� LL221.a <br />