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�. 2 <br />an J00gU1h County Public Health Sores <br />Environmental Health Division <br />Medical Waste Management Program <br />APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION <br />To quality for a "Limited Quantity Hauling Exemption" pursuant to the "Medica( <br />conditions must be met Waste Management Act", thefollowing <br />The generator or health ceras professional ganecates less than 20 pounds of medical waster per week, transports less <br />than 20 pounds of medical WaaBte at any one time, n-mintains a tracking document pursuant to Chapter 6, and the <br />generator or parent 4rganl7etlon has on file 011e Of the t'oflaMng; <br />1- Medical Waste A48178gement Plali 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- f rormovan Document if the generator or parent organisation Is a small quantity generator not required to <br />register pursuant to Chapter 4. <br />PLEASE COMPLETE THE IWQRMIATION 13ELOW AND MAIL. WITH $87 Fee To: <br />San Joaquin County Public Health Services <br />Environmental Health Division <br />Medical WWO Management Program <br />304 E Weber Ave <br />Stockton, CA 05202 <br />Medical Weist�e Haular Information <br />Q New Renewal Medical <br />Heam $&-vices <br />Medical OfFlooMusinass Name:80County <br />Medical QfficelBusinerm Addreas: <br />fty: te', p Corse• <br />Contact I2erson: <br />Storage Facility Namix. . U C <br />atoraga Fftirity Addmss: <br />city; state:_. Zip Cade: <br />1:19MM CA <br />Permitted Treatrwnt Faeility Nafna:_S <br />Permitted Treatment Facility Address-, ESS Ul_ <br />City:.. � = 3 81 ' p Cede <br />List ail employee names and titles authorized to transport the medic W waste_ if not enough space, attach Infor <br />mation, <br />1- Name; TitlSN .-f-� n I <br />2- Name -e: <br />3^ tame. + Me: <br />A cope of this exemption and a trackhM document shall be In omplWeirs pme"srlon at all R mIn while tmnft0cMW moftal w***. in <br />addltlan, Art copfafa Of lriedlcal ""W I*c*r4s glaall be knot on fit* at ganemaws or health care protesolonars' faclirty. <br />Applicant Signature:_ �� n r] ,, it A..- <br />Do Not Write Below This tine <br />R.E.H.S. Application Approval: 1Zdata: / ELO_ xpiration Mfe: 1Z 3 O <br />>: KW1Iru�se Date Paid C or Check #__4J .J� (circle) Acc <br />