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- Sa% Iquin County Public Health Servii ooU 7g4,9 9 <br /> Environmental Health Division <br /> Medical Waste Management Program 1 <br /> APPLICATION FOIA 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 rile 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 quantityg to <br /> register pursuant to Chapter 4. v <br /> f <br /> PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH $67 FEE TO: SEP 0 s 2000 <br /> ENVIRONMENT HEALTH <br /> San Joaquin County Public Health Services PERMIT/SERVICES. <br /> Environmental Health Divisions <br /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> F <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> D New D Renewal <br /> Medical Officelt3uslness Name: <br /> Medical OfflcelBusiness Address: S18 fag- <br /> city; _ State: eA Zip Code: 94-510 <br /> 4Contact Person: —/,c=ue !-I�WzjZ2Ca Phone #: <br /> Storage Facility Name: Q <br /> Storage Facility Address: 6Z <br /> City: 3E4iGU State:_ C4Zip Coder <br /> 1 <br /> Permitted Treatment Facility Name: LEI <br /> Permitted Treatment Facility Address: <br /> City; Fd S,G%' _ State: _ 6 Zip Code: <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> I. Name: JAct A Title: <br /> 2- Name: -S Age4 1� FFE�'ir.1H _ Title: <br /> 3- Name:r� Title' <br /> A copy or this exemption and a tracking document shall be In employee's possession of all times while transporting medical waste. In <br /> addition, all copies of medical waste records shall be kept on file at generator's or health care profeaslOnal'a facility. <br /> Applicant Signature: <br /> Title H2T ES <br /> Date: <br /> 6 D <br /> Do Not Write Below This tine „ <br /> R.E.H.S. Application Approval: Date: / _J , Expiration Date: <br /> EH4502 10-03•96 Date Paid 091 D!o 1 D72__ Cash or Check s '21 6 (circle) Acct_(d� _ <br />