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01 Joaquin County Public Health Ses <br /> Environmental Health Division VP <br /> Medical Waste Management Prcgram <br /> APPLICATION FOR A LIMITED QUANTIT`f HAULING EXEMPTION <br /> T o quality for a "Limited Quantity Hauling Exemption" pursuant to the -medical Waste Management Ac: the icllowing <br /> conditions must be met <br /> i ne generator or health care professional generates less than 20 pounds of medical waste per week, transports less <br /> than ZO pounds of medical waste at any one time, maintains a lacking dccument pursuant to Chapter 6, and the <br /> generator or parent organization has an file one of the fallowing: <br /> 1- Metrical 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. m <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 cUMPLEIE THE INFORMATION BELOW AND MAIL WITH Sal FEE:: TO: <br /> San Joaquin County Public Health Services <br /> Environmental Health Division -- i <br /> Medical Waste Management Program <br /> 304 E Weber Ave <br /> Stockton, CA 95202 <br /> Medical Waste Hauler Information <br /> New�ene�=val <br /> Medical OfncelBusiness Name: <br /> ;Medical office/Business Address: Code: c�?= <br /> Stag: C'y Z P —1- <br /> City: P Phoned <br /> Contact Person: G <br /> Storage Facility Name: <br /> oCK <br /> y <br /> Storage Facility Address: Siete: Zip Code: <br /> Permitted Treatment Facility Name: <br /> permitt. Treatment Facility Adder: \ State: Zip Cade: <br /> City: <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> ` 1Itie: <br /> 1_ Name: ` Title: <br /> Z- Name: 'title: <br /> 3- Name: n �1� m`4 <br /> 1� document dull be in employee's possession at all times white transporting made waste- In <br /> A copy of thus exempt! and a tracking aonat's facility °'^ a <br /> addItIOM all copies of medlcal waste records shad be ke�on file at ener�t or health V <br /> Applicant Sig{�ature: pate: �- <br /> Title: <br /> Do Not Write Below This Line <br /> Approval: ate: <br /> �/� Expiration Cate: i3/ i d <br /> Z_ .H.S_ ,�.�clication pp a �-- <br /> ?aid ' / /g /v cas. oy G\ _� a_/ tcirde} Ac,:. _._ <br /> EH4,oa 10-03A6 Date 1i <br />