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Sanquin County Public Health Servic <br /> *nvironmental 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'Wedical 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 <br /> re to <br /> register pursuant to Chapter 4. I mired <br /> rG � �C- <br /> PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH S67 FEE TO: V%sc <br /> 0 -1 <br /> San Joaquin County Public Health Services \AEi�� <br /> Environmental Health Division ���1R�Ni� jjSFS <br /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> 0 New C3 Renewal <br /> Medical Office/Business Name:. y <br /> Medical Offic?iBusiness Address: 1 57- <br /> City: 1 -0 V T State: -Zip Code: <br /> Contact Person: tC E 1Phone <br /> Storage Facility Name:—jLl>VA-A,,,C- EA./7 P- <br /> Storage Facility Address: f 3 <br /> City: L0 h T SW., -_Zip Code: q1 3 .2-q- 6 <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility A 0 C <br /> '7 <br /> City: C-ff-6 t j ^k- _State: CLA--Zlp Code: <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> - .5 R — <br /> I- Name: l2 -tC-Ko r--A-pt-S�-T-:E-t-->T- title: A- R-T <br /> 2- Name: R <> !vL Title: <br /> ----7-- Title: <br /> 3- Name: T 0-41 A/f- A—L 0. f J ® <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 shall be kept ar"le at geggratoes or health care professional's facility. <br /> Applicant Signature: soe <br /> Title: vE2--r- 0 ---Date: A 91�6' <br /> Do Not Write Below This Line <br /> 1R.E.H.S. Application Approval: 12 AI/I 1 14— Date: 1124 Expiration Date:ILL:k—/Zo <br /> EH4502 10-03-96 Date Paid ' /'Q I" Cash o4S ` � _11-2-1 q ­(circle) Acct <br /> LoveP-PA It^xCFVQ� r—Xo-v%, -3/f L�(- <br />