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Safoaquin County Public Health Servj* Environmental Health Division Medical Waste Management Program APPLICATION FOR 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: 1- 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 COMPLETE THE INFORMATION BELOW AND MAIL WITH $67 FEE TO: San Joaquin County Public Health Services cco)pc�y Environmental Health Division Medical Waste Management Program 304 E Weber Ave Stockton, CA 95202 Medical Waste Hauler Information ❑ New A Renewal —� Medical Office/Business Name: ` FAITN U,4 Medical Office/Business Address /Y N r Aj-rrA--' J ti City: SZ� State: � Zip Code: y 5.x90 Contact Person: Phone #: Storage Facility Name: FC77; L 7P Storage Facility Address 91 u A) (6F City: �I' State: CA Zip Code: 957;-6:- Permitted Permitted Treatment Facility Name: 'PEi T,►4- Permitted Treatment Facility Address: 9# QEw7c-,Z T City: S-1-CCrc.r16-A-I State: CR Zip Code: 9S_26 Z List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. 1- Name: Sq9-P, d�)u,'�,c.� A) Title: i i/� J C.h/lu)C S1-f/'r/,CAS 2- Name: fL S r Tti rS`' ti Title: A:'0 3- Name: 11,R A_!, A /N 14 L d 12 A_V9 Title: A copy of this exemption and a tracking document shall be In employee's possession at all times while transporting medical waste. In addition, all copies of medi76-La- Title: ste records be kept on rile at generator's or health care professional's facility. Applica Signature:I -_ l Lt Date: // / 'Li / 52 Do Not Write Below This Line R.E.H.S. Application Approval: Date: Z/ / Expiration Dater EH4502 10-03-96 Date Paid / / Cash or Check #_��u (circle) Accts ' �_