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Ah-joaquin County Public-Health Se <br /> - 'qW 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- /nformadon 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 V',RTHS-40FEE TO: /_\YM ENT <br /> San Joaquin County Public Health Services <br /> RECEIVr=D <br /> Environmental Health Division �a <br /> Medical Waste Management Program <br /> 304 E Weber Ave oV4 jOrc uw COUNTY <br /> PLBLIC HC-ALTH S€RVMS <br /> Stockton, CA 95202 vv����r�^;,rI,ITA�HEALTH DiVISION <br /> Medical Waste Hauler Information <br /> hn <br /> All New G Renewal <br /> Medical Office/Business Name:. <br /> ///�// <br /> Medical Office/Business Address: o cry <br /> City: State: CA Zip Code: S'>--o <br /> Contact Person: Phone <br /> Storage Facility Name: C,- <br /> Storage Facility Address: / <br /> City: -f State: C 4 Tp Cade: -z-o <br /> Permitted Treatment Facility Name: �'� �` Iwo — <br /> Permitted Treatment Facility Address: - <br /> Ci State: Zp Code: <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, information. <br /> 1- Name: Z_lA/v Sd aAf6 , ��P Title: <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 spaU be kept on file at generator's or health care professionars facility. <br /> Applicant Signature: - <br /> Title: Date: <br /> Do Not Write Below This Line <br /> R.E.H.S. Application Approval: Date: 110/ / iration Date: 2/f! /d <br /> EH4502 10-03-96 Date al / 3 / Cash 0 eC (circle) ACCs <br />