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*San Joaquin'County Public Healt*-rvices <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 /> 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 $67 FEE TO: <br /> San Joaquin County Public Health Services <br /> Environmental Health Division <br /> Medical Waste Management Program co D <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> C3 New 9 Renewal <br /> Medical Office/Business Name: <br /> Medical Offi /Business Address: 141 <br /> City: G State: e'er� Zip Code: <br /> Contact Person: Phone#:,109 4/6 <br /> i <br /> Storage Facility Name: <br /> Storage F� ility Address: <br /> City: � �o •LJri State: Zip Code: 9��D�- <br /> Permitted Treatment Facility Name: e l <br /> Permitted Treatment Facility Address: r <br /> City: �74At� State: ti Zip Code: �. <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> 1- Name: 1/# d Title: &P <br /> 2- Name o Title: <br /> 3- Name: Title: <br /> A copy of this exe n and a tracking documen hall be in employe 's possession at all times while transporting medical waste. In <br /> addition, all copies of in c waste records sha be pt on file a speratoes or health care professional's facility. <br /> Applicant igna ur <br /> Title: Ll Date: <br /> Do Not Write Below This Line <br /> R.E.H.S. Application Approval: r > Date: / / Expiration Date: 3/ <br /> EH4502 10-03-96 Date Paid // / ab / J�� Cash o Chec l3 (circle) Acct <br />