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Saaquin County Public Health Se es <br /> roEnvironmental Health Division W <br /> Medical Waste Management Program <br /> MEDICAL WASTE TRACKING DOCUMENT <br /> (To be used with the "Umited Quantity Hauling Exemption" form only) <br /> Medical Office/Business Name: <br /> Medical Office/Business Address: <br /> City: —State: -Zip Code: <br /> Phone Number: Contact Person: <br /> Name of Person Hauling Medical Waste: <br /> (Must be person authorized on "Limited Quantity Hauling Exemption" application) <br /> Quantity of Medical Waste Hauled: Date Hauled: <br /> (Not to exceed 20 pounds/week) <br /> Type of Medical Waste Hauled: <br /> Permitted Treatment Facility Name: Permit #-: <br /> Permitted Treatment Facility Address: <br /> City: —State: -Zip Code: <br /> Date Medical Waste Received: <br /> Signature of Authorized Treatment Facility Representative: <br /> X Title: Date: <br /> FILL OUT INFORMATION BELOW ONLY IF MEDICAL WASTE IS NOT BEING <br /> TRANSPORTED DIRECTLY TO A TREATMENT FACILITY [i.e., Medical Waste is being <br /> transported to (I.) a permitted storage facility or(2.) a veterinarian or a home health care nurse is hauling <br /> medical waste back to own facility.] <br /> Storage Facility Name: Permit <br /> Storage Facility Address: <br /> City: State: Zip Code: <br /> Date Medical Waste Received: <br /> Signature of Authorized Storage Facility Representative: <br /> X Title: Date: <br /> HAULER SHALL KEEP A COMPLETED COPY OF THIS DOCUMENT ON FILE FOR 3 YEARS <br /> EH 35 03 09-27-95 <br />