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r <br /> oa uin Cour Public Health Sergi. <br /> S a�rrJ q tY <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION , <br /> Exemption" <br /> ursuant to the Wedical.'Naste Management Ac:', the following <br /> 'To quality Hauling for a "Limited Quantity g p p <br /> conditions must be met: j <br /> i he generator or health care professional generates less than 20 pounds or medical waste per weak, transports less <br /> ,han 20 pounds or medical waste at any one time, maintains a tracking document pursuant to Chapter S, and the <br /> generator or parent organization has on Tie one of the following: <br /> 1_ Medica! 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- <br /> 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 INF ORMATlON BELOW FIND MAIL W H $vc FEE 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 /> Medic I Waste Hauler formation I <br /> Nelx Renewal Sfi.��s CcNhmw+�i i1�c�� , 1 21y. �7: ais 3fj•,k ' <br /> T ` e <br /> - Jv S ` vN vyr�c�r`a �. �cr Y� <br /> Med office/Business Name' 3 {� Q �(j2`I <br /> Medical Office/Business Address: 3 a <br /> Tp Cade: S�� <br /> vc State: c 4 <br /> City: G Phone w. S /O <br /> Contact Person: <br /> Storage Facility Name: S65'e 1 c Ca <br /> Ct �i4 't <br /> Storage Facility Address: State: —Zp Code: <br /> City: <br /> Permided Treatment Facility Name: S <br /> '.S �`Cu <br /> —V ) <br /> Permitted Treatment Facility Address: UO State: _Zip Cade: <br /> City: <br /> ist all employee names and titles authorized to hmnsport'the medical waste. if not enough space, attach information. <br /> -� �•d wte S rtle: <br /> Name: Tie; <br /> 2- Name: title: <br /> 3- Name: i <br /> possession at ail times while transporting medical'��- In <br /> A copy of this exemption and a tracking docetmen!shall be in employee's essiarsal's racility. <br /> addition, all copies of medical waste eros s be kept an fate at enerators or health care <br /> I <br /> Applicant Signature_ " j.. <br /> U r !n?eN Date. <br /> Title: , <br /> Do Not Write Below This Line <br /> Date_ 1 IQ pica#on Date: 2131 ! O ZZ <br /> Q.E.H.S. Application Approval <br /> 4A��EH45o2 16-03-96 <br /> Date Paid 1 C, �7 L Cash a hec`< ' f 45b � _(circle) Acct <br />