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FROM ENGINEERING DEPT *AX NO. : 209 468 6186 F0 28 2001 04:53PM P2 <br />San Jo2cluin County Public Health Son/ice.3 <br />Environmental Health Division <br />Medical Waste Management Program <br />APPLICATION FOR A LJMITED QUANTFFY HAULING EXEMPTION <br />To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Act', the 'allowing <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 Capter 6, and the <br />generator or parent organization has on rile one of the following: <br />I- 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 INFORMA110N BELOW AND MAIL WITH S67 FiE 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 />C1 Now & Renewal <br />Medical Offica/Business Name:— <br />Medical Office/Business Address: <br />City_ FRENCH CAMP, — <br />Contact Person: Chuck Peek <br />N CO. HEALTH CARE SERVICES DEPARTMETN <br />P.O. BOX 1499 -,!!c <br />CA -ZIP Code: 95231 <br />Phone -Fr- 468-6166 <br />Storage Facilib/ Name, N/A <br />Storage Facility Address: <br />City- State: Zip Code, <br />Permitted Treatment Facility Name, SAN JOAQUIN GENERAL HOSPITAL <br />Permitted Treatment Facility Address: 500 WEST HOSPITAL ROAD <br />City: FRENCH CAMP _State: Zip Code: 95231.._.__._- <br />List <br />52.31 <br />I ist all employee names and Wes authorized to transport 'the medical waste. If not enough space, attach information. <br />11- Name: Max Cervantes ride: llousekeepi.pg Service Worker <br />2- Name' Jose L01!ez Title: 't I I TI <br />3- Name. Luis Huante Title: 41 It <br />A copy of this exemption and a tracking doc=ant shall be in employee's possession at all times while transporting medical waste. In <br />addition, all copies of medical roasts ye,,Tor$�; tihall be kept an file at generators or health cam professional's facility. <br />Applicant S <br />Title: Facilities mana-aer Date: 12 / 1.2. / 00 <br />Do 11,lot Write Below This Line <br />q,.E.H.5. Application Approval: a Date:Expiration Date: _4�4131 01 <br />EH4602 1043-96 Date Paid 0 1 Cash or Chet' <br />(Circle) A= <br />