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San#quin County Public Health Servido <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 Act", the following <br /> conditions must be met <br /> T he generator or health care professional generates less than 20 pounds of medical waste per week, transports less <br /> than 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 /> 1- Medical Waste Management Man 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- 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 /> 0 New Renewal <br /> Medical Office/Business Name: "U4,A vec�QAA_ <br /> Medicg4Qffice/Business; Address:-. <br /> City:. A I ttate:- C9A Zip Code: <br /> Contact Person: '�W\()QQ1 M Phone <br /> Storage Facility Name: <br /> Storagp,F <br /> ,acility Address: <br /> City: Zip Code. <br /> Permitted Treatment Facility Name: 16V1 <br /> PermiffLld Treatmen dress: <br /> City:_ Al�kk T p Code: <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> 1- Name: /_e�r t1,\rVVC%_ Title: <br /> 2- Name: T"itle: <br /> 3- Name: Title: <br /> A copy of this exemption and, a trmacituingdocument shall be in employee's possession at all times while transporting medical waste. In <br /> h� <br /> addition. all copies df`?ffFWj=1 a shall be kept on file at generatoes or health cars professionars facility. <br /> Applicaignatur_- <br /> Title: <br /> DoNotWrite Below This Line <br /> R.E.H.S. Application Approval: ,--Qate: XI& Expiration Date: /Woo <br /> EH4502 1043-96 Date Paid Cash or�C�ck , (circle) Acct <br />