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San Joaquin County Public Health ServicA Environmental Health Division Medical Waste Management Program APPLICATION FOR A LIMITED QUANTIr( HAULING EXEMPTION To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Act,% the following conditions must be met The generator or health care professional generates less than 20 pounds of medical waste per week, transports less than 20 pounds of medical waste at any one time, maintains a tracking document pursuant to Chapter 6, and the generator or parent organization has on file one of the following: Medical Waste Management Plan if the generator or parent organization is a large quantity genehator or a small quantity generator required to register pursuant to Chapter 4. 2- Information Document if the generator or parent organization is a small quantity generator not required to register pursuant to Chapter 4. PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH S67 F—EE TO: PAYMENT San Joaquin County Public Health Services RECEIVED Environmental Health Division JAN 15 2003 Medical Waste Management Program 304 E Weber Ave SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Stockton, CA 95202 ENVIRONMENTAL HEALTH DMSIOIN Medical Waste Hauler Information 0 New ZRenewal Medical office/Business Name: ............. �4 6 c> Medical office/Business Address: CL State: f 77p Code: City: r Phone #:2-�q Contact Personi L) Storage Facility Name: 15 J1 Storage Facility Address: ti State: Zip Code: ri City: Permitted Treatment Facility Name: S:k Permitted Treatment Facility Address: V State: -Lkl_Z1p Code:--?�� City:- L List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. rr Name: Title: Title: 2- Name: Title: 3- Name: A copy I of this exemption and a tracking document shall be in employee'spossession at all times while tim parting medical waste in addition, all copies of medlqai waste records stag be kept on file at generators or health care professionars facility. Applicant Signature: Date: Title: Do Not Write Below This Line / ADa R.E.H.S. Application Approval: Date: q�/o Expiration Date -ffS� Acct EH4502 10-03-96 Date Paid Cash of�5 < _ �(circle)