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0 <br />San Joaquin County Public Health Services <br />Ved <br />Environmental Health Division <br />ical Waste Management Prog <br />To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste <br />Management Act', you are required to meet the following conditions: <br />1- Your medical office/business generates less than 20 pounds of regulated medical <br />waste per week. <br />2- Your medical office/business transports less than 20 pounds of regulated medical <br />waste at any one time. <br />3- Your medical office/business maintains records of any regulated medical waste <br />transported offsite for treatment and disposal, including the quantity of the waste <br />transported, the type of the waste transported, the date the waste was <br />transported, the name of authorized person that transported the waste and the <br />destination of the waste. <br />PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH $67 APPLICATION FEE TO: <br />P AYMEN <br />San Joaquin County Public Health Services Qafft IA17 r <br />Environmental Health Division <br />P.O. Box 388 <br />Stockton, CA 95201-0388 <br />Medical Waste Hauler Information <br />Medical Office/Business Name: <br />Medical Office/Bus� 'nes Address: <br />City: G j <br />Contact Person: <br />Permitted Treatment Facility Name: <br />Permitte�&vc�, <br />atme Facility A dre: <br />City:fl ����� <br />f <br />SAN JOAQUIN CQU dT'r <br />PUBLIC HEALTH SERVICF <br />G-�CiI a,', /y+ I�1lv;7k L 1 <br />Please list employee names and titles authorized to transport the medical waste." <br />1- Name: `i /%' J' �t �0 V ) e l C� %t1 <br />2- Name: r►�. r 2 _ e9 w Q eN C- <br />3- Name: �k'�4 �r_ i i' /I N ked �n / <br />�c� pOed -_�G /Gar 1 J`/ p ,(,/ J",) .� j <br />If transportingmeth I waste to a etmstory a facility -for or consolida on X1P s oi�if veterinarian or <br />home health care nurse transporting medical waste back to own facility, please complete the following: <br />Storage Facility Name: Zed), P r± 8 � !' �V' i .�G'/ <br />Permit #: ��/6Z� <br />Storage Facility Address: 10Z <br />City: __ lG� State: c Zip Code: o! <br />A copy of this exemption and a tracking document containing the information above shall be in <br />employees possession at all times while transporting medical waste. In addition, all copies of <br />medical waste records shall be kept on file at your-facility- <br />Applicant <br />ou facility. <br />Applicant Signature: �" � Title•^ � --//e: <br />j&7 / �/ / A Q. <br />R.E.H.S. Application Approval: Date: / Iq <br />EH 45 02 09-27-95 <br />