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` Sj6oaquin County Public Health Servs; es <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 />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 COP <br />Medical Waste Management Program' <br />P.O. Box 388 <br />Stockton, CA 95201-0388 <br />Medical Waste Hauler Information <br />❑ New E1 Renewal <br />Medical Office/Business Name: DP 1 :t a Blood Rank - <br />Medical Office/Business Address: 65 N Commerce Street <br />City: Stockton State: CA Zip Code: 95202 <br />Contact Person: Cathi Feiock Phone* (2.09) 943-3830 <br />Storage Facility Name: Delta Blood Bank <br />Storage Facility Address: 65 N Commerce Street <br />City: Stockton State: CA Zip Code:_ 95202 <br />Permitted Treatment Facility Name: BFI Medical Waste Systems <br />Permitted Treatment Facility Address: 9719 Lincoln Village Drive Suite 501 <br />City: Sacramento State: CA Zip Code: 95827 <br />List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. <br />1- Name: <br />See attached list 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 />addition, all copies of medical a records shall be kept on file at generator's or health care professional's facility. <br />Applicant Signature: 1—' <br />Title: Medical Direc Date: <br />Do Not Write Below This Line <br />R.E.H.S. Application Approval: Date: / 8 /9�Expiration Date: <br />EH4502 10-03-96 Date Paid /a / AO / q6 Cash Chec `fq39 (circle) Acct <br />