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{ <br /> Sa � {.agdin County Public Health Serv' <br /> Environmental Health Division 796 <br /> Medical Waste Management Program F1/-,) <br /> PiP�-v8r� z <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> i 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 24 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 /> F 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 $P7 FEB TO: <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> 304 E Weber Ave c��_ <br /> s� <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> P"'N'ew ❑ Renewal <br /> Medical Office/Business Name: r <br /> Medical Office/Business Address: <br />` City:_ T3c�f1 c:r� _State: CA Zip Code: <br /> Contact Person: Phone : A;,6 4(/,e-71�� <br /> Storage Facility Name: <br /> Il Storage Facility Address: <br /> City: r t1E Slate:4* Zip Code: <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: q/ <br /> City: ���� _ State: _1i Zip Code: <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information_ <br /> 1- Name: Title: &4&z44a <br /> 2- Name: Title: " <br /> 3- Name: j:S"z o Title: it <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 medicai ste records shall be kept on file at generator's or health care professional's facility. <br /> i Applicant Si nature: <br /> R2 Date 9 12W 1 <br /> Title: <br /> Do Not Write Below This Line <br /> R.E.H.S. Application Approval: -VI, Date: g12 /WExpiration Date: /G, 1 3/ 1 14 <br /> EH4502 10-03-96 Date Paid �/ / � ash or Check 4- F F) (cirri Acct <br />