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Sa Joaquin County Public Health Sero <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"Medical.Waste Management Ac:', 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 6, and the <br /> generator or parent organization has on ale 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 Sol FEE T^: - <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 /> Med;,pt- Waste Hauler I formationNew RenewalLSw�te �' Qbure i r e <br /> 1 Jv S V l vrirC°�r`a�� r�vt✓ <br /> Medical office/Business Name'. e R j,12`I <br /> Medical office/Business Address: State: G%� Zp Code: S�a� <br /> City: v c Phone#7 9SY�f 0U <br /> Contact Person: - <br /> Storage Facility Name: X05 Ca t <br /> Storage Facility Address: State: � G4 Zip Code: ' <br /> City: <br /> Permitted Treatment Facility Name: <br /> 1)__18 ca <br /> 111 7 <br /> Permitted Treatment Facility Address: UO State: Cade: <br /> City: <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br /> kz c./�'�li�f/�1/Y�et/r�S Title: <br /> 1- Name: Title: <br /> 2- Name: Title: <br /> 3_ Name: <br /> A co of this exemption and a tracking document shall be in employee's possession at all times while transporting medical waste. In <br /> copy 6e kept on fiie at generators or health care professional's faciBty. <br /> addition, all copies of medical waste ords s <br /> Applicant Signature: .... <br /> ef Date: <br /> Title: <br /> Do Not Write Below This Line <br /> R.E.H.S. Application Approval <br /> Date/_�'/��piradon Date: Z ` i D Z <br /> EHaso2 io-o3-96 Date Paid Jr / i'/ b2 Cash o het< 145b�� (circle) AcR <br />