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Say oaquin County Public Health Sery <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 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 /> te at any one time, maintains a tracking document pursuant to Chapter 6, and the <br /> 'hon 20 pounds of medical was <br /> generator or parent organization has on file one of the following: <br /> 1- Medical Waste Management <br /> Plan <br /> iif the <br /> generator <br /> to r pa rent 4 ganization is a large quantity generator or a small <br /> quantity generator req to 9 <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 567 F–EE 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 /> n Newienewal , <br /> Medical Office/Business Name: <br /> Medical office/Business Address: State:S Z Code: C ` <br /> City: n . Phone m � <br /> Contact P rson --, 'q` i; o` Cti <br /> Storage Faciiibj Name: <br /> Storage Facility Address: State: T!p Code: <br /> City: <br /> Permitted Treatment Facility Name: <br /> Permitted,Treatrnent Facility Address: State: Zip Cade: S� <br /> City: <br /> 1^ <br /> ort the medical waste. If not enough space, attach information. <br /> List all employee names and titles authorized to transp <br /> Title: <br /> 1- Name: Title: <br /> 2- Name: Title: <br /> 3- Name: <br /> f7 ie �i/' cls at all times while transporting medical waste. In <br /> �� <br /> A copy of this exemptldh and a tracking document shat! be in employee's possession professional's faeiiity. <br /> addition, all copies of medical waste records shad be kept on file at generatoes or health care prof <br /> Applicant Si ature: Oate: <br /> Title: r ¢ <br /> Do Not Write Below This Line <br /> ate:�f LPi� on Oaie: l�0 I d <br /> 4.E.H.S. Application Approval: 5a9�7 (circle) Acct_ — <br /> EH4;02 t0-03-96 Date Paid Cash o ec< <br />