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San ,,oaquin County Public Health Servs <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 Ae% 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 /> 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 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 WITH S67 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 Tr Renewal <br /> Lodi Memorial Hsopital, LMH Home Health Agency, -- <br /> 't , haaa�3 artivitia4 <br /> Medical office/Business Name:__ <br /> Medical Office/Business Address: 975 S. Fairmont Av Sta[e._C& Zip Cade: Aslan <br /> City: Lodi Phone '209-339-7668 <br /> Contact Person: Donna McCaule <br /> Storage Facility Name: <br /> Storage Facility Address: 975 s. Fairm A State: CL Zip Code: 95 AD- <br /> City: Lodi <br /> Permitted Treatment Facility Name: s <br /> Tnr- <br /> Permitted Treatment Facility Address: State: ('A_ Zip Code: 95742 <br /> City: Rancho Co <br /> 1-ist all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> Title: <br /> 1- Name: Title: <br /> 2- Name: Title: <br /> 3_ Name: <br /> A copy of this exemption and a hacking document shall be in employee's possession at all times while transporting medical waste. in <br /> addition, all copies of medical waste records shall kept on file at generator's or health care professional's facility- <br /> Applicant <br /> acilityApplicant Signature: 1� ° Date• 12 / 02 /az__ <br /> Title: Facilities Coordinator <br /> Do Not Write 3elow This Line <br /> Date:1 f �/® piration Date: 6� 3/ 1 b <br /> R.E.H.S. Application Approval: - icircle) Acct -Z <br /> EH4502 10-03-96 Date Paid �2/ / ® Cash or Chec< = r-• .z---- <br />