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Saaquin County Public Health Servi` <br /> Environmental Health Division <br /> t <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 he met <br /> The generator or health care professional generates less than 20 pounds of medical waste per week, transports less <br /> than 20 pounds or 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 Fc'E 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 Hauier'Information <br /> ❑ New ❑ Renewal <br /> Medical Office/Business Name: A&-S <br /> Medical Office/Business Address: <br /> City: State. C4 Zip Code: S 4 <br /> Contact Person: u� A 44ot Phone m: 'DD 4/b�-7 d <br /> Storage Facility Name: . ks <br /> Storage Facility Address:_ �5 l8 .9,-6 G7 -- - - - - <br /> City:_ E3EN Gi"moi - _... Stater- ---•,._,,.Zip Code: <br /> Permitted Treatment Facility Name: F' <br /> Permitted Treatment Facility Address: 413a l✓. SdU�f=! /�U< _. <br /> City: F/ �-'y' State: GA _ 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: <br /> 2- Name: owC �cS Title-. <br /> rtle: suit <br /> 3- Name: !O <br /> -,v z <br /> i <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medkal waste. in <br /> addition, all copies of medical wawa records shag be kept on fife at generator's or health rare professional's facility. <br /> Applicant Signature: <br /> Title: Date: <br /> Do Not Write Below This tine <br /> Q.E.H.S. Application Approval: Date: /OI Expiration Date:L! I <br /> EH4502 10-03-96 Date Pai Cash o heck u (circle) Acct <br />