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Sa*quin County Public Health Servilp <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 /> ,han 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"OFEE T0: 'P%YMEENT <br /> San Joaquin County Public Health Services <br /> i-,E0EIVEl7 <br /> Environmental Health Division Lt�7 3 �i � ; <br /> Medical Waste Management Program <br /> 304 E Weber Ave ;AN JOAUUIN COUNTY <br /> PUBLIC HEMI H SERVICES <br /> Stockton, CA 95202 FNVIRONMFNTA!.HFALTH DIVISION <br /> Medical Waste Hauler Information <br /> New ❑ Renewal �� t? <br /> Medical Office/Business Name:. 4A/ Sd 6 16 wiAi <br /> Medical Office/Business Address: o n-X / l <br /> City: v L -l � State: C A _Zip Code: S J <br /> Contact Person: Phone T o <br /> Storage Facility Name: &o c�- L! S�u�` CC- » !,"p� <br /> Storage Facility Address: l/f alv <br /> City: -f —State: Tip ode: <br /> Permitted Treatment Facility Name: bra-DJ +-1-11 m--? <br /> Permitted Treatment Facility Address: - o <br /> Cl.ty. nom}. , - ------ - State: C_Zip Code:ttLT <br /> List all employee names and, tititles authorized to transport the medical waste. If not enough space, attach information. <br /> 1- Name: Z-1,4A Sd WAA!64, AV-P Title: -wt(7 <br /> 2- Name: Title: <br /> 3- Name: Title: <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 medical waste records s d be kept on file at generator's or health care professional's facility. <br /> Applicant Signature: - <br /> Title: r Date: <br /> vlIg719 Pao sal vi, ill 9,07 <br /> W-' 557 479046622 Do Not Write Below This Line <br /> R.E.H.S. Application Approval: Date: / / Expiration Date: <br /> EH4502 10-03-96 Date Paid lb / 3 /a Cash o ec! �(circle) Acct <br />