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d ` T• <br /> Sa & quin County Public Health Sery <br /> Environmental Health Division <br /> Medical Waste Management Program <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 6, and the <br /> generator or parent organization has on file one of the following: <br /> _ 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 /> ❑ Newenewal <br /> Medical Office/Business Name: J+ Q�0-� �JrClJ( 1�1LvT ' <br /> 47 <br /> Medical Office/Business Address: Ct ��S ne State: Zip Co Code: <br /> City: <br /> Phone ?o` <br /> Contact Person: : /-Gi67�y�L <br /> Storage Facility Name: <br /> Storage Facility.Address: N� f <br /> City: 1�[��rN' State: Zip p Code: 2f C/ <br /> Permitted Treatment Facility Name: S ®f <br /> Permitted Treatment Facility Address: ' °��� <br /> r `z State: CeA Zip Cade: -14 <br /> City: <br /> List all employee names and titles authorized to transport the medical waste. If not enough space, attach information., <br /> 1- Name: J �1� Title: <br /> Title: <br /> 2- Name: Title: <br /> 3- Name: <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 /> addition, ail copies of medical wasterecords shad be kept on file at ge rotor's or health caro prefessionars facility. <br /> Applicant Signature: <br /> Title: �1d�� _ !/'& A`LI ( r',jtel Date: //— / ?U / 02— <br /> Do Not Write Below This line <br /> R.E.H.S. Application Approval Date: / / Expiration Date- / <br /> EH4502 10-03-96 Date Pai p� / /.3 /O3 Cash or _ D (circie) Acct _._ <br />