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t <br /> San aquin County Public Health Servi <br /> Environmental Health Division <br /> Medical Waste Management Program <br /> APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br /> To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Ac:', 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 /> ,han 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 file one of the following: <br /> �- Medical Waste Management Plan if the generator or parent organization is a large quantity generator ora small <br /> quantity generator required to register pursuant to Chapter 4. <br /> 2- 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 INFORMATION BELOW AND MAIL WITH S67 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 /> Medical Waste Hauler Information <br /> ❑ New Renewal <br /> Medical Office/Business Name: <br /> Medical ce/Business Address: State: Zp Code: <br /> City: Phone#-. Q— <br /> Contact Person: <br /> Storage Facility Name: <br /> Storage Facility Address: State: Zip Code: <br /> City: <br /> Permitted Treatment Facility Name: - -5A Y lc <br /> Permitted Treatment Facility Addres-s: 41 Z <br /> -State: Zip Cade: 5'7 <br /> City: n <br /> i ist all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> Title: <br /> 1- Name: Title: <br /> 2- Name: Title: <br /> 3- Name: <br /> A copy oLSignatu xem an ckin document shall be in employee's possession at ail times while transporting medical waste. In <br /> addition, ie of medical rec u kept o eat generator's or health care professional's facitity. <br /> ApplicaDate:®t /olTitle: " <br /> Do Not Write Below This Line <br /> Q.E.H.S. Application Approval. k �-P� Date: /F / Expiration Date: <br /> EH4502 10-03-96 <br /> Date Paid 1 / 3 / ®1 Cashr Chec!< s 71.3_ X77 (circle) Acct Z! % <br />