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♦ T <br /> Sa*aquin County Public Health Service <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 /> 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 required to <br /> register pursuant to Chapter 4. <br /> PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH S67 FEE 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 /> New;K Renewal <br /> Medical Office/Business Name: C PJ JO- MutJ <br /> Medical Office/Business Address: Z(aO 'C. 1F <br /> City: IJ State: CA Zip Code: <br /> Contact Parson Phone C�57— RS" <br /> ___ <br /> . 1 �p� eeF SAN JDA&U n� <br /> Storage Facility Name <br /> Storage Facility Address: E P EWE <br /> State: Zip Cade: <br /> City: <br /> Permitted Treatment Facility Name: <br /> Permitte(LTreatment Facility Address: e <br /> City: (Z40c.Jo C6(44'*)b14A State: G Zip Cade: a <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> 1- Name: 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 shad be kept on file at generators or health care professional's facility. <br /> Applicant Signature: <br /> Title: 0 b i A) Date: <br /> Do Not Write Below This Line <br /> R.E.H.S. Application Approv Date: / / Expiration Date:/Z/.31 /0000 <br /> EH4502 10-03-96 Date Paid / /3/ Cash o Chec' !aro 3 (circle) Acct <br />