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4 <br />San Joaquin Count Public Health Servi <br />q Y cZ''s <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 conditions <br />must be met. <br />The generator or health care professional generates less than 20 pounds of medical waste per week, transports less than 20 pounds of <br />medical waste at any one time, maintains a tracking document pursuant to Chapter 6, and the generator or parent organization has on <br />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 quantity <br />generator required to register pursuant to Chapter 4. <br />Information Document if the generator or parent organization is a small quantity generator not required to register pursuant to <br />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 <br />304 E. Weber Ave. <br />Stockton, CA 952QZ <br />Medical Waste Hauler Information <br />❑ New 1Y Renewal <br />Medical O usiness Name: Kaiser Permanente <br />Medical Office/Business Address: 7373 West Lane <br />City: Stockton State: CA Zip Code: 95210 <br />Contact Person: Monica Gray Phone #: 209-476-5444 <br />Storage Facility Name: Kaiser Permanente <br />Storage Facility Address: 7373 West Lane <br />City: Stockton State: CA Zip Code: <br />Permitted Treatment Facility Name: Kaiser Permanente <br />Permitted Treatment Facility Address: 7373 West Lane <br />State: CA _Zip Code: <br />City: Stockton �S�lO <br />List all employee names and titles authorized totransport the medical waste. If not enough , attach <br />information. <br />1. Name: Please see attached list Title: <br />2. Name: Title: <br />3. Name: Title: <br />A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In <br />addition, all ical waste records shall be kept on file at generator's or health care professional's facility. <br />Applicant Signatu e: D� CA _ <br />Title: 6WO Tr<lli •� < GSE �� ��y-/ Date: D <br />Do N ow This Lme <br />R.E.H.S. Application Approval: Date: 111b d Expiration Date: 1 10 <br />EH450210-03-96 Date Paid: ®3 Cash or Check: circle) Acct d� <br />