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San Joaquin County Public Health Se es <br />Environmental Health Division <br />Medical Waste Management Program <br />APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />10 qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Wase Management Ac, the following <br />conditions must be met: <br />ical waste per week, <br />sports <br />ess <br />i he generator or health care professional genera(ess ma gins an a tracking docupounds of ment pursuant to Chapter 6, and <br />`han 20 pounds of medical wase at any one time, <br />generator or parent organization has on fie one of the following: <br />_ Medical Waste Management Plan if the generator or parent organization is a targe quantity generator or a sinal! <br />quantity generator required to register pursuant to Chapter 4. <br />2- <br />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 1NFORMA'nON BELOW AND (MAIL tiVM4 $S? FEE TO: <br />San Joaquin County Public Health Services <br />Environmental Health Division <br />Medical Waste Management Program <br />304 E Weber Ave <br />Stockton, CA 95202 <br />Medical Waste Hauler Information <br />n New X-5. Renewal rMi Memrial Hospital, <br />Thi Hom Health Ageney / <br />based activities & events <br />LMHClinics and all IM <br />cmmmity <br />Medical office/Business Name: 975 S. Fasrrront Avenue <br />Address: <br />CA Zp Code: 95240 <br />Medical Office/8usiness <br />Dodi <br />State: <br />Phone Y209 339-7668 <br />City: a ey <br />Contact Person: I�ont1 <br />Storage Facility Name: Todi memorial Hos ital <br />airrront <br />Storage Facility Address: • <br />State: CA Zp Code: <br />City: <br />tericyc e/ Tnc <br />Permitted Treatment Facility Name: <br />er <br />Permitted Treatment Facility Address: <br />State: Zp Code: <br />City: Rancho Corc'iova <br />and titles authorized to transport the medical waste. if not enough space, attach information. <br />List all employee names <br />See Attached <br />rile: <br />_ Name. <br />Title: <br />2- Name: <br />Title: <br />3_ Name: <br />be in employee's <br />possession at all times white transporting medical �- in <br />A copy of this exemption and a bmckine} document shall <br />Shall be kept fits at generator's <br />ar health care prof essional's facility. <br />addition. all copies of medical wast$ records <br />Applicant Sign <br />Title: <br />Do Not Write Below This Line <br />R.E.H.S. Application Approval: <br />Date Paid l2 / 20 / 1 I' <br />EH4502 io-03-96 <br />Date: I !®0T4%piratjon Date: /Z-/ //d2— <br />Cash or Check # 4' 3 (circle) Acct <br />