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San oaquin County Public Health Servi -0 <br /> Environmental Health Division <br /> Medical Waste Management Prcgram <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 feilowing <br /> conditions must be met: <br /> The generator or health care processional generates less than 20 pounds of medical waste per week transpans 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 Sle one of the following: <br /> - 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- Inrorr^ation oocument if he generator or parent organization is a small quantity generator not required to <br /> register pursuant to Chapter 4. <br /> P 5E COMPLETE THE INFORMATION W 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 95202 <br /> Medical Waste Hauler Information <br /> r New G Renewal L � G`v � s`t.t <br /> Medical Office/Business Name._CDT-t t1 ur,) <br /> Medical office/Business Address: - - <br /> Ci �� n u�-,.� a..> - . State: ��°r �p Cade: cT��- <br /> �/ Phone "r. cjL4U-ti�� <br /> Contact Person: Rr?.� 0,P F- i-U� <br /> Storage Facility Name: _ G <br /> Storage Facility Address: i-)-9c 1.�i�i�NF� - N <br /> State: CA <br /> Zp Cade: <br /> City: L <br /> Permitted Treatment Facility Name: 22i <br /> Perrnitted Treatment Facility Address: �" - iY'��`� i<1✓ <br /> City: p.�,G�' G>}�. 1✓rt State: C A 7p Cade: <br /> List all employee names and titles orized to transport the medical waste. If not enough space, attach information. <br /> '��r✓1�ti:_ yV� ,'���» Title: <br /> ;- Name: <br /> 2- Name: iP),A i--,>)j Title: <br /> ,.3.) Title: <br /> 3- Name: �:� ?. . M t_O ICA t_ <br /> ti c p ;off 5 6 - <br /> N c P ee's assessicn at ad time white�ars3porCng medical waste. in <br /> A copy of this axe m on a d a tracks g�ocument shat{ be in employ P professional's facility. <br /> addition, all copies of me cal waste records shall be kept an file at generatoe's or health care <br /> Applicant Signature• ('Y/.j <br /> Date: <br /> Title: <br /> Do Not Write Below This Line <br /> R.E.H.5. Apication Approval Date:�t/lQExpiration Date: 1�/31 /00 <br /> /CR Cash or Check Acs <br /> EHa5o2 iO4�-96 Date Paid <br /> h_ <br />