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w IL <br />Stoaquin County Public Health Ser s <br />Environmental Health Division <br />Medical Waste Management Program (C(0[py <br />APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Act", 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 o^, 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 $67 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 />❑ New In Renewal Lodi M M- rial Hospital Home Health Agency, Lodi Memorial Hospital <br />Clinics, Heritage Sdhool Clinic, Lodi Memorial Co m-mmity Events <br />Medical Office/Business Name: <br />t Ave <br />Medical Office/Business Address: ��Dn <br />City: Lodi State: rA, Zip Code: 95240 <br />ContactPerson: rev r. , c pr Phone #: 334-3411 <br />Storage Facility Name: Lodi. Mawrial Hosoital <br />Storage Facility Address: 975 S. Fairr=t Ave. <br />City: Lodi State: CA Zip Code: 95240 <br />Permitted Treatment Facility Name: BFI <br />Permitted Treatment Facility Address: 332E Fitzgerald <br />City: Randto Cordova State: CA Zip Code: 95742 <br />List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br />1- Name: SEE ATI'A® Title: <br />2- Name: Title: <br />3- Name: Title: <br />A copy of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In <br />adeiitien_ all cooles of medical waste records shall be kept on file at generator's or health care professional's facility. <br />App) <br />Title <br />R.E.H.S. Application Approval: <br />EH4502 10-03-96 Date Pai <br />Do Not Write Below This Line . <br />^ n Date:12 131 / <br />Acct <br />or � eck. # (Z Z OCA (circle) <br />