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Joaquin County Public Health S es Environmental Health Division, Medical Waste Management Program my APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION,vr. nz To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Act', the following conditions must be met: The generator or health care professional generates less than 20 pounds of medical waste per week, transports less than 20 pounds of medical waste at any one time, maintains a tracking document pursuant to Chapter 6, and the generator or parent organization has on file one of the following: 1- Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a small quantity generator required to register pursuant to Chapter 4. 2- Information Document if the generator or parent organization is a small quantity generator not required to register pursuant to Chapter 4. PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH $67 FEE TO: San Joaquin County Public Health Services Environmental Health Division Medical Waste Management Program P.O. Box 388 Stockton, CA 95201-0388 t ❑ New [R Renewal Lodi Memorial Hospital Home Health Agency, Lodi Memorial Hospita Medical Office/Business Name: Clinics, Heritage School Clinic, Lodi Memorial Community Events Medical Office/Business Address: 975 S Fairmont City: Lodi State: CA Zip Code: 95740 Contact Person:_ Rob Wangler Phone * 334-3411 Storage Facility Name: Lodi Memorial Hosgi tal Storage Facility Address: 975, S Fairmont— City: Lodi State: CA Zip Code: 95240 Permitted Treatment Facility Name: B 1 Permitted Treatment Facility Address:, 3326 Fitzeerald City: Rancho Cordova State: CA Zip Code: 95742 List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. 1- Name: Please see attached list Title: 2- Name: Title: 3- Name: Title: A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. in addition, all copies of medical waste re9prds shall be kept on file at generator's or health care professional's facility. Applicant Signature: / U— LV Title: Safety/Security oo din^ r,r Date: 12 / 20 / 96 Do Not Write Below This Line R.E.H.S. Application Approval: 4,dx, Date: 1/ 15 /_ piration Date:__j / / EH4502 10-03-96 Date Paid / / i ash or Check #_J(circle) Acct