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SJoaquin County Public Health Serk....ys Environmental Health Division Medical Waste Management Program APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Ac"', the following conditions must be met: The generator or health care professional generates less than 20 pounds of medical waste per week, transports less than 20 pounds of medical waste at any one time, maintains a tracking document pursuant to Chapter 6, and the generator or parent organization has an file one of the following: 1- Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a small quantity generator required to register pursuant to Chapter 4. 2- Information Document if the generator cr parent organization s a small quantity generator not required to register pursuant to Chapter 4. PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH 567 FEE TO: I San Joaquin County Public Health Services - Environmental Health Division l� terr_)E :I ,'I�L) Medical Waste Management Program 304 E Weber Ave �L i 9 ��j Stockton, CA 95202 ENVIRONMENT HEALTH Dr.- Medical rMedical Waste Hauler.Information ❑ New CS Renewal ,Medical Office/Business Name:_Ag=� I-JC- nc44 7-C14 Medical Office/Business Address: 2770 4A L City:_ 1r/ft� �7 -mac Stale: C _Zip Cade: X45 97 Contact Person: JA jc At--g.4A)oAg�e - Phone m: 925 76Z-d Storage Facility Name: 1-4S 9C1449wJAIle N-' _ - Storage Facility Address: .5`I�1 84-4;L CT City: _ 3c daC,1A GG `/ State: -CA _ZP Code: _94 /a Permitted Treatment Facility Name: Cid/ Permitted Treatment Facility Address:_ 4/367 ick S VJF- A i/k _ - - City: Q�6AID- State: C4 Zip Cade. List all employee names and titles authorized to transport the medical waste. if not enough space, attach information. I 1- Name: "IAC Tile: 2- Name: LE Tit1e: �AfLTi✓CR 3- Name:_ Title: iEC�l�rllCi,��1 A copy of this exemption and a tracking document shall be in employee's possession at 2H times while transporting medical waste. In addition, all copies of medical waste records sh2U be kept an file at generator's or health care professionars facility. Applicant Signature: -- R S Date: Title: /I i Do Not Write Below This Line R.E.H.S. Application Approval.. Date: Z/2cIV-7 Expiration Date:Q— ' — PP pP EH4502 10-03-96 Date Paid _ / ` 1- Cash ` s (circle) Acct