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�1 San ' juin-County.Public Health Servic��b 1 environmental Health Division ! Medical Waste Management Program APPLICATION FOIA A LIMITED QUANTITY HAULING EXEMPTION To qualify for a "Limited Quantity Hauling Exemption" pursuant to the"Medical Waste Management Act", 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 on file one of the following: 11- 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 or parent organization is a small quantity generator not required to register pursuant to Chapter 4. PLEASE C04MPLETE THE INFORMATInN BELOW AND MAIL. WITH $67 FEE TO: San Joaquin County Public Health Services. Environmental Health Division Medical Waste Management Program 304 E Weber Ave Stockton, CA 95202 Medical Waste Hauler Information D New 0 Renewal Medical Office/Business Name: S . as CD Cen mmed Medical Office/Business Address: affN o4 _ Z" t[J• ��'�� A440,V� 4 City: State:_ CIS Zip Code:�Z "Z©sL Contact Person: Phone #: O - ?6 oZ Storage Facility Name: < < r Storage Facility Address: �ra�kr>aw State: Zip Code: j2o City; Perr!itted Treatment Facility Name: Permitted Treatment Facility Address: State: Zip Code: City: List all employee names and tines authorized to transport the medical waste. If not enough space, attach information. w -P Title: / *' f 1. i- Name: 1Z R Title: f 2- Name r2f 3- Name: Title: Athis times le transpong copy of all copies of exemption medical waste record! hall be ll be In ept on fie at generator's orlon at ahealth care profaslslonal s facimedical waste. In lity addition, p Applicant Signature: • `G Date• Tille: Do Not Write Below This Line , R.E.H.5. Application Approval: Date: ,_Expiration Date: E1i4502 1"3 -96 DateG Cash ckc ;zircle) Acct``-?