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ltd i <br /> San Joaquin County Public Health Services i <br /> Environmental Health Division <br /> Medical Waste Management Prcgram <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION i <br /> y a qualify ra <br /> T • for "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Ac:', the fallowing <br /> q � <br /> conditions must be met: r I <br /> I <br /> professional generates less than 20 pounds of medical waste per weeK transports less <br /> The generator or hea€th.care i <br /> than pounds of medical waste at any one tune, maintains a tracking dwtrinent pursuant to C:zapter S, and the i <br /> generator or parent organization has art file one of the following: f <br /> I- Medical Waste Management Plan if the generator or parent orcanization is a large quantity generator or a small <br /> quantity generator required to register pursuant to Chapter 4. l <br /> rator or parent organization is a small quantity generator not required to <br /> 2- Inrormaf an Document is the gene <br /> register pursuant to Chapter 4. <br /> PLEASE COMPLETE THE INFORMA31ON E3ELOW AND MAIL WITH 507 l-cEr TOt k <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> 304 E Weber Ave k <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> ❑ New Ei•Renewal <br /> Medical OfficelSusiness Name:. L W NJ <br /> Medical Ofsiceleusiness Address: �al�l State: Zip Cade: - <br /> City; ohone m 3�I - �,v 1 c! <br /> Contact Person: <br /> J Q lG La!t] <br /> R� �V N L_ <br /> Storage Facilit'/ Name: VD24: i R 2CJ_ �{ <br /> Storage Facility Address: 2'�fl State: Zp Cade:_ r <br /> City: <br /> -permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: State: <br /> City: CA ?p Cade: <br /> List ail employee names and titles authorizes to transport the medical waste. if oat enough space, attach infomation. <br /> i <br /> rAUi_L; W Title: ti,avec t�14t�1G �� <br /> 1- Nam. e: OE _P2C1 Title: NL DI�t f� <br /> 2_ Name: Title: Mp�c�t- 551 <br /> i <br /> 3- Name: <br /> A copy of this exemption and a tracking <br /> document shall be in employee's possession at all times while transporting medical waste' in <br /> addition, alt copies of medical waste records shall be kept an file at genera <br /> tar+s or health care prafe3sianal's fact <br /> l <br /> Applicant Signature: Date- / to 1 0 1 <br /> Tide: <br /> Do yot Write Below This Lime <br /> Date: I 1OZfxpiratian Date: r2iz <br /> R.E.H_5. Application Approval: Acct <br /> Cash or Chec< r $����(circle) <br /> - -, n;;re Paid - - - - <br />