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San Joaquin County Public Health Services <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 Ac;', the following <br /> conditions must be met <br /> The generator or healthcare professional generates less than 20 pounds of medical waste per week, transports fess <br /> :hon 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 WIT'ri $67 FSE T0: <br /> E - <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 /> r New Renewal <br /> Medical office/Business Name:. �,, C�N-�� <br /> Medical office/Business Address: dlo+-ICU E FAY��Tt* <br /> S iom�l State. Zo Code. <br /> City: Phone : 44 <br /> Contact Person: �iQlt` NI�4����►,► <br /> Storage Facility Name: GkJAN L I �- E <br /> Storage Facility Address: State: C-- Zip Cade: 91 <br /> City: <br /> Permitted Treatment Facility Name: <br /> 1'� I✓l M�D��� ��� ��� 5TH(��c u� t_� — <br /> 1 i F <br /> Permitted Treatment Facility Address: N State: Crp Code: C1 y� <br /> City: <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> Title: L -rp.1-,.? <br /> Title:_ <br /> 2- Name: Title: <br /> 3- Name: <br /> A copy of this exemption and a tracking document shall be in employee's possession at all times while tray porting medical waste. In <br /> addition, all copies of medical waste records shall be kept an file at generator's or health care professional's facility. <br /> Applicant Signature:_ y �t`� �'� f <br /> rk—Ir- Date: I�� ►� � v <br /> Title: <br /> Do Not Write Below This Line <br /> R.E.H.S. Application Approval: _ Date: / 9 / jxpiration Oate:____� <br /> 2 / �q / 4 _ Cash or Chec< :-t -571 17 (circle) Acct <br /> s,z a� Date Paid L <br />