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Joaquin County Public Health Sees <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 ac:', 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 5le 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 INFORRMAJION BELOW s.ND MAIL WI-17H $67 FEE <br /> San Joaquin County Public Health Sdrvices <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> C1 New 91 Renewal <br /> Medical Office/Business Name:. - GS 6 <br /> Medical Office/Business Address: Code: i <br /> City: b _ State: �' Zip <br /> Contact Person , G r-7 <br /> e Phone <br /> Storage Facility Name: C <br /> Storage Facility Address: <br /> City: ' Ir i-t� tai State: Zp Code: <br /> Permitted Treatment Facility Name: <br /> Permittd Treatment Facility,Address: f <br /> City: �C111C State: Tp Cade: D <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> i- Name: r�P 415 P � �C�i1 PC� 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 shall be kept on file at generator's or health care professional's faciiity. <br /> Applican Signature: <br /> Title: 0 D)^ Date: % / /I / <br /> Do Not Write Below This Line <br /> 2.E.H.5. Application Approval- --------'Date): Z!I Ib Expiration Date: gL �0Z <br /> EHa502 to 03-96 Date Paid �Z/ 1Z/ 0) Cah or Chek t— q3� lCircie) Acct�— <br />