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San Joaquin County Public Health Services <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 "4tedical 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 file one of the following: <br /> 1- Medical Waste Management Plan if the generatorto parent <br /> ter organization is a large quantity generator or a small <br /> quantity generator required to register purl p <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 $67 F'cE TO: <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> C3 New Renewal <br /> Medical Office/Business Name: <br /> 5 G� 5A� �TI)P 11-11;4 Lt <br /> Medical OfficeiBusiness Address: Z- State: Zp Code: a <br /> City: Phone T: �? <br /> Contact Person: <br /> v'��4 A3 <br /> Storage Facility Name: S <br /> Storage Facility Address: State: Zip Code: <br /> City: <br /> Permitted Treatment Facility Name: <br /> Permitt <br /> Treatment Faf�tyVAss: State: Zip Code: a <br /> City' L� <br /> ort the medical waste. If not enough space, attach information. <br /> List all employee names and tiger authorized to transp <br /> �� ����, Title: <br /> 1- Name: _ Title: <br /> 2- Name: Title: <br /> 3- Name: <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In <br /> addition, all copies of medical waste records shall kept on file at generator's or health care prof <br /> Applicant Signature: Date•��-- f�'� <br /> Title• 'TjQAJ$ <br /> Do Not Write Below This Line <br /> Date: Expiration Date:—LZ;./.5/ 1 <br /> Q.E.H.S. Application Approval: 1-t �"'''� l�EBSto (circle) Acct Zd— <br /> EHa;oz 10-03-96 Date Paid I2i a3 f D Q G <br /> ' f-°r Check <br />