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4*quin County Public Health See* <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 ANaste Management Aet', 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 /> 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 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- 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 Narne:AWK(ed d) Jn e a <br /> Medical OfficelBusiness Address: S: -EA.SZ Z-",Vd,-64 Zip Code:I 95'�P 6 <br /> JOA� State: <br /> City: S4(26 k, — );k ✓ Phone /-/S <br /> Contact Person: 1)411,�f ?7ARAVE12 5-412� <br /> Storage Facility Name:-AMeric'41u P 124 L <br /> Storage F?cility Address: 1E0 e e-r <br /> City: State: Zip Code: 9,6-,q 0 .2 <br /> Permitted Treatment Facility Name: <br /> Permitted Treatment Facility Address: 7 7 E T71 .54,-e e <br /> City: VerIVOIL) State: C,4- Zip Code: 900,?3 <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> I- Name: 57ee Title: <br /> 2- Name: Title: <br /> 3- Name: Title: <br /> A copy of this exemption and a tracking doctunent shad be in employee's possession at all times while transporting medical waste. in <br /> addition, all copies of medical w"reco shad be kept on file at generator's or health care professional's facility. <br /> ,�>,/Wp <br /> Applicant Signature:,Aj j Date: /C/ <br /> Title: 6aatl &Ea <br /> N Do Not Write Below This Line <br /> cZ.E.H.S. Application Approval 7 Date:-L-L7—Z4AX0iration Date:-LLJ�/o <br /> EH4502 10-03-96 Date Paid I-b ICI 0--d- Cash or Checks I Z,617.Z2 (circle) AcCr-T!j/—/. <br />